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Introduction and Theoretical Background --- Depression in Older Adults The world population is rapidly aging: Between 2015 and 2050, the percentage of people in the world over the age of 60 will nearly double, from 12% to 22% . Depression among older adults is one of the most serious public health problems facing modern societies . The appearance of depression is associated with serious consequences, including disability, functional decline, diminished quality of life, increased mortality, increased service utilization, and high levels of suicide in adults . In older adults, depression is connected with a marked reduction in cognitive abilities which, in turn, is commonly accompanied by a decrease in social and physical activities . Alongside coronary heart disease, cancer, and cardiovascular diseases, depression is a major public health problem that has become a common chronic disease in older adults . Depression symptoms greatly influence both physical and cognitive functioning of older adults. Longitudinal studies have reported that depressive symptoms are connected to functional decline, as determined by both self-reported and objective measures of physical performance . They also contribute to limitation of basic activities of daily living in high functioning older adults initially free from disability . As depression deepens and more symptoms surface, the likelihood of becoming disabled increases. Moreover, depressive symptoms may accelerate the disablement process in older adults already exhibiting early signs of disability , and individuals with chronic depressive symptoms have greater declines in functioning compared to those who remained nondepressed . Late-life depression is also associated with an increased risk of decline in cognitive functioning. Older adults with depression are more likely to have concomitant cognitive deficits, especially executive cognitive functioning deficits, or are subsequently more likely to develop dementia . Older adults with depression often develop cognitive impairment following onset of depression. Thus, depression might be a risk factor or an early symptom of dementia . One of the risk indicators for depression is lack of social support and social networks. Many of depressed older adults are also lonely, and a correlation has been found between depression and loneliness. Depression with feelings of loneliness leads to more pronounced motivational depletion and serious consequences, including social isolation, reduced selfcare, decreased mobility, and poor diet . participants reported loneliness feelings in the week prior to the interview. The loneliest group was that of age 75+; women reported higher levels of loneliness than men, as did Arabs compared with Jews. Today, loneliness is also perceived as a biological structure, similar to hunger, thirst, or pain, which are internal mechanisms activating behavior that prevents harm to the person. Hunger makes us seek food; loneliness prompts us to seek social relationships . Correlations have been reported between the feeling of loneliness and several physical health problems: cardiovascular diseases, chronic diseases, cancer, stroke, high blood pressure, and mental illness , low levels of emotional wellbeing, and a high level of suicidal thoughts . The problems caused by loneliness lead to decreased quality of life, increased mortality, poor recovery from illness, and high hospitalization rates among older adults . Depression in older adults may result from a variety of reasons apart from loneliness feelings, including malnutrition. Some studies have reported a strong and independent association between nutritional deficit and depression, demonstrating that depression increased the risk of impaired nutritional status , whereas others have shown a modest association, or no association . Significantly, over 10% of adults with depression residing in the United States also suffer from malnutrition . Malnutrition impacts quality of life by undermining individual autonomy to perform necessary, instrumental, and social activities of daily living . Malnutrition is defined as a state in which a deficiency, excess or imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form , function, and clinical outcome . It is more prevalent and increases among older adults . Although malnutrition's etiology is multifactorial, adverse physiological, psychological, and social causes of malnutrition in older adults are consistently reported in the literature . Aging is accompanied by physiologic changes that can negatively impact nutritional status: Sensory impairment may result in reduced appetite and poor oral health and dental problems can lead to difficulty chewing, inflammation, and a monotonous diet that is poor in quality. The progressive loss of vision and hearing may also limit mobility and affect the elderly's ability to shop for food and prepare meals . Along with physiologic changes, older adults may also experience profound psychosocial and social changes contributing to poor nutritional status. These include cognitive impairment, heavy use of medication, periods of lengthy hospitalization isolation, retirement from paid work, bereavement, increasing frailty, and loneliness and depression . These factors influence the ability of older adults to meet dietary needs or to digest, absorb, utilize or excrete nutrients that are ingested. The outcome is reduced energy intake and lean body mass, resulting in a reduced metabolic rate and a proportional decline in total energy expenditure that may lead to malnutrition . Apart from the possible direct connection between loneliness feelings and depressive symptoms, loneliness feelings can have widespread implications for the mental and social lives of older adults, and these implications can explain some of the effects of loneliness feelings on depressive symptoms. Specifically, one mediator might be at play -malnutrition. --- The Current Study The current study was conducted in Israel in 2020 during a Covid-19 pandemic quarantine, providing a unique opportunity to assess the effect of loneliness feelings on depressive symptoms, mediated by malnutrition, among older adults from different cultures during a particularly stressful period. We posited three hypotheses: 1. Loneliness feelings due to the Covid-19 pandemic is associated with depressive symptoms. 2. Loneliness feelings due to the Covid-19 pandemic are indirectly associated with depressive symptoms through malnutrition; older adults feeling lonely will report higher levels of malnutrition, which will be associated with increased depressive symptoms. 3. Loneliness feelings, depressive symptoms, and malnutrition levels will differ between older adults from different cultures as a result of Covid-19 imposed quarantines. --- Method --- Study Design and Participants The research employed a cross-sectional study of a convenience sample of 201 Jewish and Arab older adults, aged 65 and over, representing the two main ethnic groups living in Israel. Inclusion criteria were age 65 and over and the ability to speak and understand Hebrew or Arabic. --- Procedure The study was approved by the Research Ethics Committee of the college at which the research took place. Recruitment of participants was random and the final sample comprised 100 Jews and 101 Arabs. Researchers explained the study objectives and procedure to the participants, including their right to withdraw freely at any time. Strict confidentiality was maintained. Data collection was performed by professional interviewers through telephone interviews, adhering to Covid-19 quarantine restrictions, using appropriate translated, validated, and structured questionnaires. Data collection took place from April to May 2020. --- Measures --- Independent variable Loneliness. Loneliness was measured by a single direct question: «Do you sometimes feel lonely?» with four options: never, seldom, sometimes, often. --- Dependent variable Depressive symptoms. Depressive symptoms were measured by the Geriatrics Depression Scale developed by Yesavage and Brink . The purpose of the questionnaire was to determine participants' depressive symptoms by using a simple and reliable tool that does not require the time and skills of a professional interviewer. The tool is composed of 15 items, in a yes / no response formats . --- Mediator Malnutrition. Malnutrition was measured by the Determine Nutrition Screening Initiative developed jointly by the American Diabetes Association, the American Family Doctors Association, and the National Council of Old Age. The purpose of the questionnaire was to detect older adults at risk for malnutrition. The tool is composed of 10 items, in a yes / no response format. --- Covariates The study controlled for socioeconomic variables. Background variables included gender, age, marital status, and years of education. Age and years of education were both defined as continuous measures. Gender was coded as dichotomous . Marital status was coded as "with partner" = 1; or "without a partner" = 0. All instruments were translated into Hebrew and Arabic by bilingual translators. The complete questionnaire underwent a pilot test. The questionnaire took approximately 15 minutes to complete, the verbal instructions were comprehensible, and there was no need for further changes before administering the questionnaire. --- Data Analyses Descriptive statistics were employed to calculate the means and standard deviations of the continuous variables and the percentage and frequency of the categorical variables. In the second stage, bivariate analyses were performed to examine the association between depressive symptoms and the independent variable, mediator variable, and socio-economic variable using an independent t-test, one-way ANOVA, Pearson or Spearman correlation tests. Mediation analyses were then computed in which the selected mediator was entered to test the components of the mediation model using the bootstrapping method to assess the indirect effects of the mediation model . Thus, the meditation model was examined by directly testing the significance of the indirect effect of the independent variable on the dependent variable through the mediator , while controlling for background variables that were identified earlier as significant in the bivariate analyses. This method is based on regression analysis, calculating the direct effect , total effect and indirect effects of an independent variable on a dependent variable. The total and specific indirect effects were calculated through bootstrapping set at 5,000 samples. Confidence intervals were calculated using this method by sorting the lowest to highest of these 5,000 samples of the original dataset, yielding a 95-percentile confidence interval . All analyses were run using SPSS 25.0 with the PROCESS statistical program . All estimated effects reported by PROCESS are unstandardized regression coefficients. --- Results Of the participants, 105 were women and 96 were men, ranging in age from 65 to 95 . Years of education ranged from 6 to 21 and 71.1% had a partner. The group had equal numbers of Arab and Jewish participants. There were significant differences based on ethnicity with regard to education, with Jewish participants reporting more years of education than Arab participants; the Cohen's effect size value was high. Arab participants reported a significantly higher level than Jewish participants of loneliness , malnutrition , and depressive symptoms . For most variables, the Cohen's effect size values were relatively high . Table 2 presents the bivariate tests between the study variables with depressive symptoms as the dependent variable. Results revealed that all demographic variables, except for gender and marital status, were significantly related to depressive symptoms. Advanced age was positively correlated with depressive symptoms. Lower educational level was correlated with higher reported depressive symptoms. An ethnic difference in depressive symptoms was also found with Arab participants reporting higher depressive symptoms than Jewish participants. Both the independent and mediator variables were significantly related to the dependent variable-depressive symptoms. High malnutrition and high loneliness were positively associated with depressive symptoms. --- The Mediation Analyses Using PROCESS model 4, we tested hypotheses two and three, whether malnutrition mediated the relationship between loneliness feelings and depressive symptoms controlling for covariates . The results indicated a significant total direct effect of loneliness feelings on depressive symptoms, a significant direct effect, and a significant indirect effect through malnutrition. The results also showed that loneliness feelings were associated with higher malnutrition scores and that malnutrition was positively associated with depressive symptoms. Finally, ethnicity was associated with depressive symptoms. However, no significant associations were found between depressive symptoms and the other covariates: gender, age, education, and marital status. --- Discussion The general purpose of this study was to examine the extent to which loneliness feelings are connected with depressive symptoms of older adults from different cultures during isolation by conducting research during a Covid-19 pandemic quarantine in Israel. We measured whether older adults who suffered from higher degrees of loneliness feelings due to the Covid-19 quarantine had higher levels of depressive symptoms and what potentially accounted for this association. The findings confirmed the first hypothesis that older adults suffering from a high degree of loneliness feelings suffer from higher levels of depressive symptoms. These results are consistent with other studies executed before and during the Covid-19 pandemic, reporting that loneliness feelings are associated with mental wellbeing . The mediation model confirmed the second hypothesis that the connection between loneliness feelings and depressive symptoms is accounted for by level of malnutrition. The association between loneliness feelings, depressive symptoms, and level of malnutrition can be explained by two different aspects: dietary behavior and the influence nutrition has on depressive symptoms. With regard to dietary behavior, loneliness feelings may affect appetite and nutrient intake through a decline in mood, physical functioning, or cognition . These various declines combine with the difficulty people have eating alone. Appetite can be further inhibited by changes in social status, particularly when older adults experience loneliness and/or bereavement due to loss of a spouse or friends of the same age-group . Eating in the company of others can help prevent malnutrition. It increases caloric intake and is related to healthier food habits , and maintains the motivation of older adults to eat and cook, providing them with opportunities for social interaction and connectedness . The current study took place during a Covid-19 quarantine when older adults, as a high-risk group, were counseled to stay at home with their permanent partners only and to avoid, as much as possible, from going shopping and to depend on home deliveries. Hence, it is likely that older adults were forced not only to eat alone, but to be alone most of the time, resulting in insufficient food intake and, consequently, malnutrition. The second aspect concerns the connection between depression and the diet of older adults. Recent studies have suggested that depressive symptoms are more prevalent in individuals with impaired nutritional status than in other older patients. It has been observed that individuals with specific nutritional deficiencies such as lack of folic acid and vitamin B12 as well as antioxidant vitamins had more depressive symptoms than those with normal nutritional status . The mechanism that might be at work here is that older adults who suffer from loneliness feelings tend to eat less and lack a healthy appetite and, for that reason, they will not consume all the nutrients they need and will suffer from malnutrition or depressive symptoms. This mechanism accelerates during a quarantine, when even older adults who do not suffer from loneliness ordinarily suffer from isolation. The third study hypothesis was that research variable levels will differ between cultures, particularly due to the extremity of the Covid-19 quarantine. Indeed, Arab older adults reported greater loneliness feelings, higher level depressive symptoms, and greater malnutrition compared to the Jewish older adults. The results with regard to depressive symptoms are consistent with studies reporting that being a member of an ethnic or racial minority is a risk factor for depression. Specifically, Arab respondents have reported higher depressive symptoms than Jewish respondents ; however, there are also contradictory results . Concerning the higher levels of loneliness and malnutrition, the Covid-19 quarantine may have posed new challenges to the Arab study participants that explain the study findings. Arab society in Israel is known for family consolidation and solidarity. The extended family maintains a multi-generational structure, with grown children obligated to filial piety responsibilities . The Covid-19 quarantine forced new ways of communication upon family members, exposing the absence of digital literacy among Arab older adults: for Arab older adults, Internet use does not protect against loneliness . Moreover, the extended family often lives together, with the daughters and daughters-in-law cooking and serving the older adults . The quarantine isolated the Arab older adults from their extended family, resulting in reduced help with cooking and serving meals. Moreover, the strong connection between feeling loneliness and malnutrition cited above amplified the problem. --- Conclusion and Implications The present study was executed during a Covid-19 pandemic quarantine. The results indicate that there is a connection between loneliness feelings, depressive symptoms, and malnutrition. The primary conclusion is that loneliness feelings are a serious problem facing all older adults since they negatively affect both depressive symptoms and malnutrition. In order to overcome these feelings, it is important to connect older adults to social network technologies and teach them how to use these technologies. Families can also receive guidance for meeting while maintaining social distancing. Another option is to encourage neighbors in the same building to talk to each other and find ways for mutual support. Research indicates that members of the Arab society in Israel are a high-risk group and much more vulnerable to loneliness feelings, depressive symptoms, and malnutrition in times of crisis such as the Covid-19 pandemic. The lives of many Arab older adults changed from being surrounded and supported by their extended family to being alone during the quarantine and to suffering from malnutrition. In order to fight these two related outcomes, one possible solution is to provide psychological-nutrition intervention by telephone. This would provide by missing human contact and nutrition guidelines and encouragement to cook and eat healthier foods. We should point out three main limitations of the current study. One is the cross-sectional study design, which does not allow for prediction of a causal relationship between the variables. A future study should use longitudinal data to examine the relationship between loneliness feelings and depressive symptoms. A further limitation might be the use of only one question concerning loneliness feelings. However, previous studies have also used one question in order to describe loneliness feelings . Third, a generalization of the findings is limited because the sample and the sampling procedure do not guarantee the representativeness of Jewish and Arab older adults. The sample was conducted by telephone and included only older adults who answered the telephone at that moment. Those who did not answer or did not have a telephone are not represented in this study. These various factors may have biased the results. Despite these limitations, the present study provides initial insights into the mechanisms of the association between loneliness feelings, malnutrition, and depressive symptoms during periods of quarantine imposed isolation. --- Conflict of Interest Statement: The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. --- Ethical standards: The number of the approval from Tel Hai College is 3/2020-5.

Research on loneliness conducted in different countries has demonstrated that it is a common, universal phenomenon, although its prevalence varies between societies and cultures (11). In the United States, more than 19% of older adults aged 65 and older reported loneliness feelings (12); in Australia, the comparable figure was 40% (13). In a study of loneliness in Israel ( 14), it was found that nearly half (47.

Introduction There are disagreements about, and contradictory indications of, the state of qualitative inquiry as a global endeavour. Denzin , for example, argues that qualitative inquiry faces a global onslaught from conservative and neo-liberal critics, especially in the field of educational research, and especially in the United States following the writing into legislation of the requirement for federal educational research funding to be allocated to so-called 'scientific' research . 'Scientific' research has been extensively defined in US legislation, and includes reference to "measurements or observational methods that provide reliable and valid data across evaluators and observers… evaluated using experimental or quasi experimental designs…with a preference for random assignment experiments…" ). The argument of critics is that qualitative research is not scientific, or not scientific enough, and cannot produce definitive evidence about 'what works' in social policy interventions. Qualitative research produces too many disconnected, non-cumulative studies that do not provide convincing evidence for central education, health, business and so forth . A key point that Atklinson and Delamont make is that qualitative research is still widely funded in countries such as the UK paper for the UK Department of Education, the terms of the debate may be changing in the UK). Delamont and Atkinson also note the development of a number of successful interdisciplinary journals in the field along with increases in the numbers of issues per year of these journals and thus the numbers of papers published. They also note the continuously expanding market for qualitative research methods texts and sourcebooks such as Sage Handbooks and Major Works, not least Denzin and Lincoln's Handbook of Qualitative Research, now in its fourth edition . There are some disagreements in the field then, in some respects representing different interpretations of the prospects for qualitative inquiry in the USA and the UK. However, what I want to argue in this paper is that these disagreements rather miss the point. The issue is not whether or not qualitative approaches to social research are developing across disciplines and continuing to receive funding and policy attention in diverse countries around the world, but rather to what purposes are qualitative methods being put? What research agendas are being pursued, and who sets them? It is clear that qualitative methods are indeed being taken up widely across regions and disciplines, with the scale and scope of the annual International Congress of Qualitative Inquiry from which this special issue derives being part of the positive evidence. It is also undeniable that, internationally, social research in general, qualitative approaches to social and educational research in particular, have been under very specific attack for fifteen year or more . Criticism is manifested in different ways, and with different levels of severity, in different countries and different disciplines. The pressure derives from concerns about the quality and the utility of social and educational research more generally, not just concerns about qualitative approaches . It also derives from an increased government focus on value-for-money in research, and how social research might better serve social policy . Qualitative methods of inquiry can be seen to play to this policy and utility agenda as much as to a social justice agenda, or indeed a disinterested scientific agenda. Qualitative methods can be deployed in policy-driven research as well as in more open-ended inquiry, and thus may survive and even prosper, but not necessarily in ways that all qualitative researchers will welcome. Researchers and evaluators in many applied research fields including health care and education have noted the reduced timescales now associated with qualitative work, and the narrowness of many research agendas being pursued . This is also the case in what we might term the more traditional disciplines of anthropology and sociology. Mills and Radcliffe report on the increasingly truncated timescales for anthropological fieldwork and the use of a more limited range of ethnographic methods among 'freelance development consultants ' and in development agencies such as the World Bank. Thus while it can be argued that qualitative research remains widely supported, the form that such research takes might be said to be somewhat limited, and even of poor quality, given arguments for exploratory and extensive field immersion that are apparent in many ethnographic textbooks. Such an orientation towards the use of qualitative methods is apparent in a range of policy development settings and intervention agencies. Thus for example, Valerie Caracelli , writing from the perspective of the US Government Accountability Office, argues for the inclusion of qualitative methods in evaluation studies "to assure contextual understanding" . She states that: Recently, there has been an acknowledgement about how ethnographic studies can inform agency actions and how it can be used to study culture in organisations . However whether truncated timescales and narrow policy agendas can be easily reconciled with the theory and practice of 'ethnographic studies' is a moot point. Moreover studying 'culture in organisations', in order to 'inform agency actions' seems to suggest the utilization of qualitative inquiry as as technology of government, rather than as an approach to understanding emergent issues that policy may not want to address. A recent UK Cabinet Office report produced in the context of the move toward evidenceinformed policy and practice presented guidelines for judging the quality of qualitative approaches and methods. Interestingly, one of the key quotes in the report used to justify the use of qualitative methods comes not from the epistemological or methodological literature, but from a civil servant, a government department "research manager": I often commission qualitative research when it's about users or stakeholders and . . . It is in this context of the potential co-option of qualitative inquiry to the agendas of policy that I want to focus on a particular sub-issue of this wider debate: that of research selectivity and concentration in the UK and its implications for qualitative research methods. Significant changes are being enacted in the UK, with regard to university finance, governance and the nature of scholarly activity, that carry potentially very severe implications for the practice of social research in general, and for qualitative approaches to research in particular. There is an argument that social research is increasingly being nationalised and corporatized in the UK -seen by many social researchers as well as policymakers as an arm of government and more important to universities for its incomegenerating potential than for its contribution to knowledge and the public good. Thus arguments about whether or not qualitative approaches to research remain popular are rather irrelevant. What is at stake is the legitimacy and quality of the research which is being undertaken, and the purposes to which it is being put. As noted above, policymakers, and some social science scholars themselves, have argued that social and educational research, particularly qualitative research, is too often conceived and conducted as a small scale 'cottage industry', producing too many small scale, non-cumulative studies which do not provide firm evidence for decision-making. It is axiomatic to such criticisms that providing evidence for policymaking is indeed the proper role for social science. Additionally, governments around the world are seeking better value for money from their investment in research and university teaching, and this has involved restricting and focusing resource allocation. Selectivity and concentration of research resources are particularly being pursued in the UK. The Conservative dominated coalition government is cutting public spending in the wake of the 2008 banking crisis and global recession; so there are fewer resources available for research than might otherwise have been the case, and selectivity and concentration have become even more severe in the UK over the last couple of years. Concentration of research is effected both through focused core allocations from the higher education funding agencies and through highly competitive bidding to research councils and foundations as described below. Success leads to further success and to relatively few universities securing the overwhelming majority of available funding. This in turn produces the issue of universities seeking research funding first and foremost for their own corporate survival, rather than for the public benefits that may accrue. It also leads to social research becoming part of a nationalized approach to managing national social problems, rather than being part of an international community pursuing better understanding of the nature of social problems and what produces them. Funding agencies and individual universities are now concentrating resources on fewer research units and programs, and are taking decisions to develop a 'big science' model of social science. This is being pursued by funders supporting fewer, larger projects, with explicit policy encouragement for researchers to develop cross-institutional, mixed method approaches, to address the supposedly 'big issues' of our time: health and well being, an aging population, sustainable growth, and so forth. These issues are indeed important, and research evidence should be produced to interrogate and inform public debate. But such issues are being presented as part of a common-sense, taken-for-granted trade-off of government funding in exchange for social scientists serving policy. Critique, diversity of perspective, and the insight into complexity which detailed qualitative studies can provide are potentially being marginalized. Social science is being reconceptualised as a technical service to government rather than developed as a democratic intellectual resource for the community. The remainder of the paper will provide some brief illustrative examples of policy initiatives and how this change is being accomplished. --- Funding universities University policy and funding is located in the UK government department of Business, Innovation and Skills -evidence in itself of where government priorities lie. Universities are not housed in the Department for Education . A recent BIS White Paper stated quite clearly that "we intend to maximize the impact of our research base on economic growth" . It went on: To compete effectively the UK must harness its strengths in…research…and its expertise in areas such as design and behavioural science… . In essence the White Paper argues that investment in research should be oriented to those areas that promise most economic return, with "behavioural science" being deployed to understand and change people's behaviour in relation to key threats to economic development such as poor health and global security. Moreover the White Paper goes on to assert that major social and economic challenges "can only be resolved through interdisciplinary collaboration" and thus government will "actively support strong collaborations" across disciplines and institutions. Research, including social research, will be marshaled and directed in the national economic interest. Such policy discourse then sets the tone for the activities of intermediary agencies such as research funding councils and individual universities. While individual research councils can set their own agenda, their budgets derive from government are unlikely to stray too far from policy imperatives. Similarly universities, while independent, must compete for specific forms of funding under common national rules and thus common institutional structures of research prioritization, monitoring and compliance emerge across institutions. The research allocation which universities receive from the Higher Education Funding Council is based on quality ratings derived from an accountability exercise originally called the Research Assessment Exercise , and now known in its current iteration as the Research Excellence Framework . As a result of these exercises funding has become highly concentrated in historically elite institutions, with, for example, only four universities receiving 32% of all HEFC research funding in 2009-10, and 25 universities receiving 75% of funding . Of course it might be argued that not receiving such funding is not necessarily such a bad thing, since it leaves the majority of universities outside the mainstream funding agenda and thus outside this particular mechanism of government control. However the mainstream agenda remains dominant since university managers simply cannot ignore it. Some research success, however small, is regarded as better than none, especially with respect to the reputational gains associated with research activity and associated student fee income. For all practical purposes, when it comes to research funding in the UK, the REF is the only game in town. Clearly, this level of selectivity begs serious issues for university finance, management and The pursuit and measurement of 'Impact' is likely to drive research activity further towards applied and policy-oriented research. Moreover the pursuit of specific research tenders and contracts is also likely to be increasingly emphasized by individual universities, as noted above, both to fill gaps in core funding left by increasing selectivity and concentration, and to maximize the metrics available for the 'Environment' element of the profile. So this element of core research funding, derived from the Higher Education Funding Council, which is intended to provide the underpinning platform for basic university research, is becoming increasingly selective and concentrated, and is now being significantly oriented towards applied rather than basic research. Thus while, technically, the agenda for this research activity remains under the control of individual scholars and research groups, increasingly they need to think about developing research programs which fit with government, university and departmental priorities, in order to maximize quality gradings and income. In turn universities and departments are developing strategies and programs to manage the REF accountability procedures, and research impact and environment issues more generally, such that research is becoming an increasingly planned, bureaucratized and managed activity. Ironically, given the current emphasis in some quarters on the 'gold standard' of scientific method, university research is ceasing to be scientific in the sense of the disinterested pursuit of knowledge and becoming a corporate, commercial activity undertaken on behalf of individual universities themselves and their financial survival. In turn, the social relations of research within universities and departments are changing. It might of course be argued that 'twas ever thus' -universities have always had to fund their activities and individual scholars and research groups have always had to manage and mediate the relationship between funding opportunities and the research that they think is important to design and undertake. My argument is that this balance of calculation is under severe pressure in the UK at the present time -both with respect to the overall funding available and with respect to the position of qualitative research activity within this funding environment. It might be further argued that this balance should change, and that the pursuit of more applied policy-oriented research should be undertaken; a second paper could be written about the issues at stake and the arguments deployed. My point for moment however, is simply that such change does indeed seem to be occurring. --- Funding social science Still, to reiterate, in principle the research agenda pursued with this funding regime remains under the control of faculty and research groups. However, another irony of the current situation in the UK is that, if anything, the funding strategy of the research council -the Economic and Social Research Council -further compounds the problem rather than providing any sort of counter weight. In principle the ESRC is an 'arms length' body, independent of government, allocating awards for excellent social science research in response to competitive bids refereed by peer review. It might be thought, therefore, that the ESRC's agenda would reflect the research agenda of the social scientific community as a whole. However all research council funding derives from government and as such is clearly influenced by government priorities; the ESRC is no exception. The ESRC shapes the content of the social science research agenda much more directly than government policy, but does so in large part, because its funds derive from government. Again, of course, there are many intermediary processes and activities, with ESRC officials seeking to maximize funding available in difficult times, in return for responding to government priorities. Likewise peers review proposals on merit but these proposals have already been produced in response to priority areas and specific funding calls. The ESRC works within the context of an overarching cross-research council strategy. There are seven research councils in the UK, distributing funds across the natural and social sciences, humanities, and medicine. Each council has become progressively more managerial over recent years, not simply responding to bids from the scholarly community for funding, but actively shaping the agenda around which bids can be made -establishing priorities and issuing specific calls for proposals, as noted above. The assumptions embedded in this statement of strategy reflect the development of an institution which sees itself governing social science rather than supporting it -defining priorities, selecting "future leaders" and concentrating PhD training in a few selected centres so that those leaders are in any case selected from an increasingly narrow institutional and intellectual base. The use of the term "training" for the development of future scholars also seems indicative of a directive rather than a supportive role. The "Deliver Plan" goes on to address this specifically and states: We will develop national capability through: …Broadening the skill of all social science PhD students by emphasizing transferable skills training…We will require institutions to provide training on core topics such as impact, public engagement and media training…to ensure the continuing pipeline of excellent researchers for the Nation . The Strategic Plan and Delivery Plan also identify a need for the longer, larger projects to be interdisciplinary and involve cross-institutional collaborations which are defined as "essential in studying and resolving complex challenges" . In effect social science is being re-conceived and re-structured as the "behavioural science" arm of government, so that social science can 'influence behavior and inform interventions'. It might be argued that because ESRC's budget and level of activity is very small when compared with overall funding for social science in the UK, its influence will be similarly small. The ESRC budget is c. £166M in 2014/15 . The total 'science' budget for UK higher education is £4.6B . Detailed breakdowns between different natural and social science allocations are difficult to identify but it is likely that ESRC does not fund more than 10% of overall social science teaching and research activity including that supported from student fees. Thus, again, there is a case for suggesting that most UK social science research is beyond the reach of ESRC and, in turn, government policy agendas. But, as with the REF, influence far exceeds scale of activity, as universities and research groups seek to bid for research council funding despite success rates dipping well below 20%, and develop postgraduate training activities to mirror ESRC provision so that they are not excluded from future funding possibilities. Nevertheless further concentration of funding might be construed as an opportunity as well as a challenge for qualitative social research, to reach out to community support and other forms of charitable, foundation and European Union funding. An interestingly critical issue for the current policy of selectivity concentration is at what point might the nationally state-supported funding base shrink so low that the research council's influence over the sector as a whole will disappear? Furthermore, there is a separate paper to be written about whether or not, and if so in what ways, social science should develop so that it can 'influence behavior and inform interventions' on behalf of government. Many would argue that social science should engage more directly with the public and help to inform democratic debate and decision-making, though such activity is not necessarily co-terminous with simply acting in response to and in support of government policy . Likewise, with respect to the content of research 'training', some would point to statistics indicating that only around 20% of research council supported research students secure academic posts in universities and thus a wider training in 'employability' is important . Yet by the same token the statistics indicate that 80% go on to work in researchrelated and more general administrative, teaching and managerial roles in other public sector, charitable and commercial organisations. If these figures are accurate then not only is such a problem not the responsibility of ESRC to solve, it is not actually a problem at all, since PhD graduates are already securing employment outside academia and the influence of social science training could be said to be extending well beyond university departments. In fact students often value these broader elements of their doctoral programs as academic employment opportunities are so limited. Nevertheless time spent on 'public engagement' and 'media training' is time not spent on fieldwork and data analysis -the core of any qualitative research training. These matters are not necessarily clear-cut, but my point for the moment is simply that these developments are shaping social science in general in the UK at the present time, qualitative educational and social research in particular. --- Short term consequences and implications The first and most obvious consequence is that relatively small scale funding to undertake specific qualitative and case study-type work is no longer available from ESRC. Hitherto ESRC ran a specific 'small grant' scheme which was able to accommodate small scale exploratory investigations, pilot projects and post-doc projects from early career researchers. It was particularly suitable for supporting individual scholars to undertake detailed case study work over the period of a year or eighteen months, by 'buying their time' to concentrate on research for short periods; and of course because the grants were small, more could be funded. In the absence of knowing in advance which project would show most theoretical and empirical advance, funding more small scale projects seems sensible. This support is no longer available. The smallest 'open call' grant now available is £200K -still modest by international standards -but substantial enough to indicate that a larger scale mixed methods approach would be more likely to win funding when evaluated against 'value-for-money' criteria. Additionally ESRC used to support a 'first grant' scheme, which was similarly oriented, as the name implies, towards early career researchers who, again, often applied for small scale funding for qualitative work. This Thus qualitative work must now be conceived and proposed either in terms of much larger scale longitudinal ethnographic investigations , or as part of a large scale, cross disciplinary and cross-institutional mixed methods research design. Again, involvement in such work is no bad thing, and no doubt will contribute to the continuing popularity which Delamont andAtkinson claim for qualitative methods in the UK, but it should not be the only qualitative research that secures support. Moreover, when such large scale investigations are only funded because government wants to 'influence behavior and inform interventions', be they mixed method or ethnographic, and perhaps especially when they are ethnographic, then they beg many questions about the legitimate role of social science in a democracy. As noted above, qualitative research 'is a wonderful vehicle if you want to understand the motives of people'. The key issues here comprise both the scale of endeavour now expected, and the control of the research agenda. Social scientists are being positioned, by government and by some leading members of the social science community as experts in social policy whose function is to respond to social problems. Again, social science should indeed be prepared to respond to social issues, but not to the exclusion of critical social inquiry. Furthermore the 'expertise' of the community depends on what we might term a hinterland of basic social theory and social research. From this hinterland expertise can be drawn and framed in response to particular issues -the move from basic to applied research. But if social science can only now act in relation to prescribed issues, problems and large scale empirical research designs then, over time, it will lose the ability to construct its objects of study independent of the context of inquiry. It will in effect cease to be social science in any meaningful sense. With respect to the social relations of research, opportunities for early and mid career social scientists to develop their own intellectual trajectories are likely to decrease as areas of strategic investment are defined by funding agencies. Moreover large scale grants are likely only to be awarded to senior researchers who have a track record of managing and 'delivering' on previously funded work. Thus early career researchers must now attend to bidding for research grants, especially in areas of applied research, and look to secure collaborative funding with more senior colleagues. This is now a core feature of any social science career. Developing scholars must also become able to design impact strategies and build networks, including with policymakers as well as other scholars, in order to become included in collaborative research designs. In effect involvement in social research is being reconstructed as a technical and professional career, and indeed a quasi-governmental career, rather than as a contribution to science, or as an independent and critical service to the community and the democratic process. The very nature of the purposes and practices of social research is being changed. My argument is not that that these matters are entirely novel or uncontentious. Social science has had an uneasy relationship with government funding for many years . Similarly, outcomes are not easily determined. There are many mediating interpretations, actions and institutional processes between grandiose policy documents, often written first and foremost to secure funding rather than control it, and the activities of individual researchers and research groups. Yet the material and discursive context of interpretation and mediation means the direction of travel becomes ever more difficult to resist. Nor is my argument that none of these things should be happening; to reiterate, universities, research groups and individual scholars have always had to fund their work and certainly should be responsive to the needs of social policy development. However, responsiveness to policy and to wider contexts of action should take their proper place in the overall career trajectories of social researchers and scholars more generally. Intellectual curiosity, about how society operates and with what effects and consequences for individuals and social groups, must remain the driving force of social science and scholarly activity. Otherwise it simply becomes a technology in service of government, rather than an independent and critical intellectual resource for democratic debate. --- Longer term trends and prospects A more general issue is whether or not the social science community is right to accept that proximity to government will necessarily ensure its sustainability. Part of the backcloth to the current debate is the uncertain status and legitimacy of both science and government at the present time. Government, and the process of mainstream electoral politics, is itself generally unpopular and under pressure 'to deliver', especially with respect to economic competence and with regard to the provision of public services. Can we always assume the benign intent and impact of government? What reasons are there for state intervention in the lives of ordinary citizens? How appropriate is it for social research to attempt to 'influence behaviour and inform interventions'? It is at least arguable that government intervention can dis-empower communities, and it certainly locates agency in government and professional bureaucracies, including those of social science, rather than local communities. A different approach would involve social research helping to build communities' capacities to develop themselves, rather than simply providing evidence for central policymaking and the development and evaluation of government intervention programs. In this respect it may be the case that deriving legitimacy for social research from proximity to government is self-defeating. Such a strategy links social research to an inherently unpopular institution and at one and the same compromises the basic claim for the legitimacy of science -that of disinterested inquiry. Of course many qualitative researchers also want to pursue a social justice agenda, not just a social scientific agenda. But here too, collaborating with local organisations, institutions and communities, rather than government, would seem to hold much more promise with respect to both the quality of the research and its potential 'impact' on social and economic life. A second element of an alternative approach to the further development of qualitative research must be to maintain involvement in international networks and debates, and resist attempts to render qualitative research into a parochial set of research techniques to be pursued in the national interest. The use of qualitative research methods has a long and distinguished history in education and the social sciences. Discussions of qualitative methodology have been at the forefront of many decades of debate over whether, and if so in what ways, we can conduct enquiry and build knowledge in the social sciences. It might even be argued that it is qualitative methods, or perhaps, more generally, a qualitative sensibility and approach, that constantly questions the development of social research as a technology. The strengths of qualitative research are at their most manifest when used to address both the substantive topic under investigation and the way in which that topic is constituted and realised in action by the social processes at play. The phenomenon under study is not simply taken as given. Thus local activity and development can draw intellectual sustenance from global debates. A key strength of a qualitative approaches to social research is face-to-face engagement with participants. This must be maintained as both an ethical and political strength, as well as an epistemological strength. Many recent international discussions of quality in qualitative research revolve around issues of engagement, deliberation, ethical process and responsiveness to participant agendas, along with the need to maintain a critical perspective on both the topic at hand and the power of particular forms of knowledge . It is these strengths of a qualitative approach that should be privileged in any discussion of their inclusion larger scale social research activities, not in order to 'influence behaviour' but in order to maximise the possibilities for the democratic development of research procedures. If research is to serve the periphery as much as the centre, in political debate and decisionmaking, then engagement of research participants in both setting the research agenda and evaluating the outcomes of the process must be developed as central to the future development of social research methodology.

There are disagreements about, and contradictory indications of, the state of qualitative inquiry as a global endeavour. The paper argues that these disagreements rather miss the point. The issue is not whether or not qualitative approaches to social research are developing across disciplines and continuing to receive funding, but rather to what purposes are qualitative methods being put? What research agendas are being pursued, and who sets them? The paper illustrates these issues with respect to the effects of research selectivity and concentration in the UK and argues that qualitative research should continue to develop as an iuntellectual resource for the community rather than as a technical service to government. policy-making. What is required is the 'gold standard' of randomised controlled trials (RCTs) for establishing cause and effect in social programs. Such criticism is not confined to the USA. In a speech to the UK's Economic and Social Research Council in 2000, titled "Influence or Irrelevance" the then Secretary of State for Education, David Blunkett (2000), asserted that Many feel that too much social science research is inward-looking, too piecemeal, rather than helping to build knowledge in a cumulative way, and fails to focus on the key issues of concern to policy-makers, practitioners and the public (p.1). More recently, similar arguments have arisen once again in a paper from the UK Department for Education. In language paralleling the US debate, the paper asserts that randomized assignment of treatment to samples is the most appropriate way to conduct research in general, educational research in particular, and that more experimental research should be undertaken in education, specifically via RCTs (Goldacre 2013). Such criticisms combine critique of methods employed, with critique of purposes pursued, arguing that social research in general, qualitative approaches to social and educational research in particular, are not responsive enough to the needs of government. So significant challenges to qualitative inquiry are apparent, but others are more cautious in their assessment of these challenges. Fielding (2010) for example shares Denzin's concerns with respect to 'the dirigisme and anti-intellectualism of the gold standards lobby' (p.127) but notes that circumstances vary internationally and that threats to qualitative research should not simply be read from a North American perspective. Others still, argue that qualitative inquiry is healthy, diverse and growing, both geographically in terms of its global reach, and in terms of its diffusion across disciplines and across applied research fields such as

Introduction Numerous studies have demonstrated that social networks have a positive effect on finding a job [1][2][3][4]. Along with the gradual introduction of social network analysis into research on China, many studies have directly focused on the Chinese labor market [5][6][7][8][9][10][11][12][13]. In general, job seekers who use social networks are able to attain higher earnings and a better occupational status than job seekers who do not use social networks. Studies on China also tend to place more emphasis on the institutional environment, linking social network analysis to the market reform process [7,11]. As an informal source of resource allocation, social networks play an important role alongside formal sources such as the market and the government. In the early stages of China's market reform, when the rules and norms of the market were not sufficiently clear, the role of social networks as informal channels for resource allocation gradually increased. As marketization deepened over time, the market rules became clearer and stronger, and the space for network-based activity declined. This means that the effect of social networks followed an inverse U-shaped trend as marketization intensified over time. However, recent research has shown that the percentage of individuals who use social networks when searching for a job does not follow an inverse U-shaped pattern as supposed; rather, it has continued increasing and, according to recent data analysis, has reached 80% . This means that it is now common to obtain help from one's social networks when seeking a job. We have strong reason to believe that those actors who use their social networks when seeking a job are not a small, special group; given that nearly 80% of job seekers utilize their social networks, the heterogeneity within this group is likely very large. Against the background of an increasing percentage of job seekers using social networks and the increase in heterogeneity, a new but very important question arises: Are the returns to social networks among those actors who use social networks when seeking a job consistent? When we focus on job seekers who use social networks, do the returns to social networks vary from person to person or group to group? This question discusses the return of social networks, which is in fact the endogeneity of social networks. Endogeneity has been a hot topic in the fields of social networks and social capital, and the existence of endogeneity has led the scholars to doubt whether there are really returns to social capital accordingly. In this study, we fully examine the complete causality and further point out the existence of group differences in the returns to social capital while discussing the returns to social capital. This will help us to answer the endogenous challenge of social networks and help us to have a more complete and accurate understanding of the returns of social networks in the labor market. --- Effects of Social Networks: The Origin of Heterogenous Returns Social network analysis has attracted abundant interest in and research on the effects of social networks since the 1970s, the beginning of the rise of social network research. Regarding whether social networks play a role in the labor market and, if so, how, various theoretical perspectives, such as the network strength approach [1,4], network resource approach [3], network structure approach [14], and network signal approach [15], have been discussed. Whether considering strong or weak ties under the network strength approach, information or favorable treatment under the network resource approach, or structural holes under the network structure approach, the effect of social networks has been comprehensively demonstrated. Among the many fields that have incorporated social network analysis, the study of the labor market has always been at the forefront of social network analysis, and the job-search process is a good context in which to examine the role of social networks. As discussed above, the effects of social networks may be diverse, as most job seekers use social networks [16]. When exploring the role of social networks, a failure to account for differences in the relationship between social networks and status attainment imposes limitations. When we move away from an overall analytical perspective and instead analyze the differences in the returns to social networks, then there are two possible theoretical assumptions: positive returns and negative returns. The social capital embedded in social networks has both instrumental and expressive effects [17]. Most of the previous studies on the effects of social networks in the labor market have focused on the income effects of social networks. In fact, the process of acquiring status in the labor market and the corresponding outcomes involve both the instrumental effects represented by income and the expressive effects of the job search process and its outcome. One of the most direct expressive effects is job satisfaction after the job search. Job satisfaction refers to the degree of satisfaction with the job found and is a subjective evaluation made by the job seeker. It is a global evaluation and may include dimensions such as satisfaction with the job itself, satisfaction with the salary package, satisfaction with the opportunities for promotion, and satisfaction with colleague relationships. The economic behavior of actors is embedded within a social structure, and job seekers might not simply choose the job with the highest salary and income when seeking an occupation but may be motivated by a global evaluation of various other non-instrumental indicators, such as colleague relationships and career development. Therefore, when we analyze the returns to social networks, we should not limit ourselves to the instrumental indicator of the returns in terms of earnings but should consider both instrumental and expressive returns. Both of these dimensions have two possible theoretical relationships with the use of social networks: positive return or negative return. --- Positive Returns Hypothesis In the social capital theory, Nan Lin describes a pyramidal social structure in which each actor is located at a certain point on the pyramid [3]. Social resources also exhibit this pyramidal structure. The higher up the actors are within this structure, the fewer positions and occupiers there are [3]. There are very few positions and occupiers at the top level, where those who control the largest number of valuable resources are located. The further up the structure one goes, the fewer actors and the more resources there are. At the bottom of the structure, the number of actors is larger, and the resources are fewer. In his theory, Lin proposed the "strength-of-position" proposition: the better the position of origin is, the more likely the actor is to access and use social capital, which is likely to be of higher quality [17]. The strength-of-position proposition is consistent with traditional structural theory, which describes the structural advantages of each actor and extends to social capital research. The initial position refers to both the actor's ascribed position and achieved position. The ascribed position is the position inherited by the individual from their parents and relatives; the achieved position refers to the social position acquired and occupied through self-effort. A better initial position results not only in more social resources being available to the actor but also in human capital, political capital, and family background advantages, among others. When social capital is combined with other advantages, it can result in combined advantages such that the whole is greater than the sum of its parts. However, actors with an average or worse initial position are at a double disadvantage: on the one hand, due to structural constraints, the social resources that they can mobilize through their social networks are inferior in both quantity and quality to those of actors with a better initial position. On the other hand, they also lack other relevant advantages that could be combined with their social capital in order to exploit the combined advantages. When an actor has a weak endowment of all types of capital, the whole may be less than the sum of its parts. In summary, the better the initial position of the actor, the more likely that actor is to use their social network. Moreover, the more likely the actor is to use their network, the greater the return from the social network is likely to be. In this paper, we take current employment earnings and job satisfaction as the returns of getting a job. So, we state the research hypothesis of positive returns to social networks as follows: Hypothesis 1.1: The more likely an actor is to use their social networks, the higher the current employment earnings they would obtain. --- Hypothesis 1.2: The more likely an actor is to use their social networks, the more satisfied with work they would be. --- Negative Returns Hypothesis Bourdieu proposed the concept of social capital in contrast to economic capital and cultural capital at the beginning of his first elaboration of capital in "The Forms of Capital" [18]. Social capital, similar to economic capital, human capital, and cultural capital, is one of "the forms of capital", and the return to such capital in terms of the income of job seekers may exhibit diminishing marginal effects with an increase in capital types. The importance of social capital is relatively minor when the actor has a sufficient number of other types of capital that can generate returns, while the importance of social capital is inevitably higher when the actor has access to fewer types of capital or even to social capital only. Returning to the pyramidal social structure described by Nan Lin, those actors who are initially in a better position have relatively superior social capital, human capital, and political capital. According to the previous literature, human capital and political capital have a positive effect on actors in the Chinese labor market [19][20][21]. Therefore, in addition to social capital, other types of capital, such as human capital and political capital, provide higher rewards to those actors who are initially better positioned. The return to the social capital embedded in social networks is a return to only one of many types of capital and is simply icing on the cake. Accordingly, for those actors with a poor initial position, the returns to social capital account for a greater share of their overall earnings due to their relative lack of other types of capital. The use or nonuse of social networks has a relatively greater or even decisive impact on such actors' earnings. For these actors, the returns to social capital obtained through the use of social networks are relatively more important and can often be a much-needed helping hand. Therefore, the better the initial position of the actor is, the more likely that actor is to use his or her social network. However, the less likely the actor is to use his or her network, the greater the returns to the social network are likely to be. Accordingly, we obtain our research hypothesis on the negative returns to social networks. --- Hypothesis 2.1: The less likely an actor is to use their social networks, the higher the current employment earnings they would obtain. --- Hypothesis 2.2: The less likely an actor is to use their social networks, the more satisfied with work they would be. --- Two Types of Selection Bias: Who Prefers to Use Social Networks? Who Benefits More from Social Networks? Pretreatment and Treatment Effect Heterogeneity On the basis of the principles of homogeneity and endogeneity, Ted Mouw raised suspicion of the social network effect in 2003 [22,23]. This resulted in a great deal of social network research in response to Mouw's challenge [24]. A variety of methods have been used to address endogeneity. These include the Heckman two-step selection model, propensity score matching, instrumental variables, simultaneous equations system, and suspicion [25][26][27][28][29][30][31]. Recently, Brand, Yu, and their colleagues pointed out in a series of studies that when we want to accurately estimate a causal relationship, we should consider all of the endogeneity along the causal chain: the pretreatment heterogeneity bias and the treatment-effect heterogeneity bias [32][33][34]. Specifically, first, people are not randomly assigned to an experimental group and a control group ; rather, people with certain characteristics are more likely to become members of the experimental group. On the other hand, people with these characteristics are not only more likely to be in the experimental group, but they are also likely to obtain benefits that differ from those of their peers without these characteristics [33,35]. Endogeneity is a universal and unavoidable problem in all social sciences. However, since Mouw's criticism of how endogeneity has been handled in social network analysis, the approach has been questioned and challenged. This is because the establishment of social networks-interactions among actors-is always purposeful and highly subjective. This makes it difficult for samples to satisfy the requirement that treatment status be randomly distributed and leads to estimation bias in the regression analysis. Given this difficulty, combined with the challenge of the complete endogeneity along the causal chain mentioned above, both of which affect the research on social networks in job search, we need to rethink the returns to social networks in the labor market. If there is endogeneity bias in the form of pretreatment heterogeneity bias, then people with certain characteristics are more likely to use social networks in when job searching. If there is endogeneity bias in the treatment effects, then people with those certain characteristics are not only more likely to use social networks but the returns that they obtain from their social networks are likely to vary, either increasing or decreasing with an increase in the likelihood of use. These two types of endogeneity bias are exactly what we try to analyze in this paper. Recent research from China has pointed out that the use of social networks in job searching is not randomly distributed and that those people who use social networks share common behavioral traits [36]. Actors who are strongly relational are more likely to use social networks when searching for a job. A preliminary study focused on investment in everyday relationships to discuss relational tendencies [36]. It has been demonstrated that the more actors invested in everyday relationships, the higher their tendency to use guanxi when engaging in instrumental actions, such as searching for a job. Apart from attitudes toward relationalism, are there any other external characteristics that identify a behavioral tendency toward relationalism? However, there is still a further problem: since social networks are not randomly selected, are the returns to social networks the same among different groups of people? This paper focuses on those people who use social networks in their job search and explores whether the effects of social networks vary from person to person. Specifically, in light of the two competing theoretical hypotheses proposed above, is it true that the more likely people are to use social networks, the higher the returns to social networks are? Or is it the case that the more likely people are to use social networks, the lower the returns are? --- Data, Measures, and Methods --- Data We used data from the 2014 Job-Search Networks survey to examine the heterogeneity in the effects of social networks on job search. JSNET2014 contains data on individuals residing in 8 large cities throughout China that is representative data with a total sample size of 5480. This survey used probability proportional to size sampling, in which a random sample was taken from three levels for each city. In each randomly selected neighborhood, households were selected from a household list through a systematic sampling technique. To obtain a complete list of both permanent and migrant households, a map of each neighborhood was drawn, and a list of the households that live there was made. From each randomly sampled household, an adult aged 18-69 was selected to be the respondent by randomly selecting birthdays. Above all, JSNET provides a representative sample and reliable results. The JSNET data are an excellent source of information about social networks and job search, which are the key variables in our research. Unfortunately, there are no more data on job search networks update after 2014. Therefore, so far, these data are the most appropriate and the latest data on the measurement of social networks and occupationally related variables. --- Measures --- Dependent Variable Earnings. "Earnings" here refers to current employment earnings, which are the occupational earnings of the worker at the beginning of their entry into their current job. This study focuses on the relationship between the social networks used by job seekers in their job search and the subsequent occupational earnings obtained, and to strictly preserve the temporal chain of causality, we directly used the occupational earnings at job entry. The rapid economic development over the past 40 years since China's reform and opening up has resulted in substantial price increases. Therefore, we used the Consumer Price Index for each city in each year to eliminate the effects of inflation, allowing occupational earnings to be comparable across each generation of new workers. Moreover, due to the right-skewness of the original income distribution, after eliminating the effects of inflation, we then took the logarithm of the earnings to bring the distribution of earnings, the dependent variable, closer to a normal distribution. Job satisfaction. Job satisfaction is a global indicator. We focused on job seekers at job entry and on the following five dimensions of satisfaction: the work itself, pay and benefits, opportunities for promotion, colleague relationships, and upper management. Each item was measured with a 5-point Likert scale ranging from "very unsatisfied" to "very satisfied". We summed up the scores across the five items and found the average, which represents the overall satisfaction of job seekers with the results of their job search. --- Independent Variables The Use of Social Networks. The use of social networks is both the most dominant independent variable in the model for predicting income and is the dependent variable in the model for predicting the likelihood of using social networks . In coding the variables, "the use of social networks" was defined not only for those respondents who directly answered that they had used social networks when searching for their job but also for those who mentioned using social networks in other follow-up questions. This is because in Chinese social life, the use of social networks, i.e., the use of connections, is often seen as synonymous with "going through the back door", which often has a negative connotation of unfairness. Some respondents were reluctant or hesitant to answer directly that they had used their social networks, but in the follow-up questions, they expressed indirectly that they had done so. --- Control Variables We measured respondents' attitudes toward relationalism by their willingness to "handle things through social networks". This is a continuous variable, with a higher score indicating that respondents were more receptive to the idea of handling things through social networks and thus that they are more accepting of relationalism. The control variables in this paper also include personal attributes, family background, and structural variables such as gender, age, hukou, education, Party membership, father's education, father's Party membership, labor market sector, an indicator for high-income industries, occupational requirements, and year of job entry. All variables used in this study can be found in Table 1. --- Methods To test whether the income return to social networks varies according to the propensity of the actors to use social networks when searching for a job, we used the stratificationmultilevel method [33] to develop our model for empirical analysis. Our approach is similar to propensity score subclassification [27] in that the whole sample was divided into a number of balanced subsamples, which were then analyzed in the next step. The specific analysis in this study followed four steps. Step 1. First, we needed to discuss the probability with which social networks are used during job search; this probability is unknown and needs to be estimated. We developed a logit regression model with a dummy variable as the dependent variable, and the resulting predicted probability is the probability that the actors use their social networks, with higher values indicating a higher probability. Step 2. We constructed balanced propensity score strata following a principle that we call "homogeneity within groups, heterogeneity between groups". Specifically, there should be no significant differences in the average values of covariates and in propensity scores between the treatment and control groups. In this study, "homogeneity within groups" means that the two types of job seekers, those who use social networks and those who do not, were randomly distributed across the subsamples defined by the propensity scores and that there were no significant differences in the distribution of those independent variables that influence the use of social networks. "Heterogeneity between groups" means that the different subsamples had significantly different probabilities of using social networks: the higher the stratification of a subsample, the more likely it is to represent the individuals in that subsample who use social networks. Step 3. Next, we estimated the propensity score stratum-specific treatment effects in terms of the instrumental returns and emotional returns to social networks. We can eliminate the heterogeneity bias in the use of social networks because of our within-group homogeneity. We can directly use multiple linear regression models to estimate the earnings and emotional returns to social networks in each subsample, which means that we can obtain the treatment effects for each stratum. Step 4. Finally, we observed the relationship between the social network effects and the ranking of each subsample in terms of propensity scores. If the social network effects are greater in the higher ranked subsamples, then there is a positive selection effect related to the use of social networks in the labor market: the more likely someone is to use social networks, the higher the return to their social network is in terms of earnings or job satisfaction. In contrast, if the social network effects are lower in the higher ranked subsamples, then there is a negative selection effect, and the more likely people are to use social networks, the less rewarding the use of those social networks will be. Specifically, to conduct this analysis, we fit the data using a variance weighted least squares regression with the ranking of the subsamples as the independent variable and the social network effects for each subsample as the dependent variable. Since the sample for this step is simply the number of subsamples, the sample size was too small for direct estimation via ordinary least squares . VWLS uses standard deviations as weights, which relaxes the requirement for homoskedasticity and overcomes the small-sample problem of OLS. --- Results --- Descriptive Statistics Table 1 presents descriptive statistics for the sample and compares both of the groups we focused on: those who use social networks when searching for a job and those who do not use social networks. The continuous variables are described in terms of their means, the categorical variables are described in terms of percentages for all categories other than the reference category, and the last column shows the results of a significance test. Clearly, there were a number of significant differences between job seekers who use social networks and those who do not. Most notably, job seekers who use social networks had higher entry-level earnings than those who do not, with the former earning an average of 340 per month ) and the latter earning only 226 ). The same trend was observed for job satisfaction: job seekers who use social networks had a mean job satisfaction value of 3.6, while job seekers who did not use social networks when seeking employment had lower job satisfaction, a value of 3.47 . However, it is not yet clear as to whether the differences in earnings and job satisfaction observed at this point are the result of job seekers' use of social networks because the binary analysis indicates that the use of social networks when seeking a job is not a random event but is influenced by numerous demographic and social factors. For example, the average age of job seekers who use social networks was found to be 29 years old, which is significantly higher than that of job seekers who do not use social networks ; those who seek jobs in the private labor market sector were found to also more likely to use social networks than those in the public labor market sector. In addition, factors such as the year of job entry, household registration at the time of the job search, education, and attitudes toward relationalism, as well as occupational requirements, all affect whether social networks are used in the job search process. --- Selectivity in Using Social Networks: The Logit Model As the descriptive analysis in Table 1 shows, the distributions of the two types of job seekers, those who use social networks and those who do not, were not consistent across many variables. To obtain an unbiased estimate of the social network effect, we first looked at the selection in social network use: who is more likely to use their social networks in their job search? We constructed a logit model with the use of social networks in job search as the dependent variable in order to predict the likelihood of using a social network. The variables included in the model to control for factors influencing the use of social networks in job search were gender, age, household registration, education, Party membership, parental education, parental Party membership, work-unit sector, an indicator for high-income industries, occupational requirements, and the year of job entry. The results are shown in Table 2. From the results shown in Table 2, it is easy to see that the use of social networks when seeking a job is indeed influenced by many factors, both personal characteristics such as age, education, household status, and attitudes toward relationalism, as well as structural factors such as labor market sector, occupational requirements, and the year of job entry. Again, this finding verifies that the use of social networks in job searching is not random but that those who use social networks share certain common behavioral characteristics [37]. People do not randomly become social network users or nonusers; rather, people with certain common characteristics become social network users. The logit model can provide a predicted probability of using social networks, and this probability value is important, as it is the basis for the stratification conducted in the next step. --- Propensity Score Strata On the basis of the predicted results of the logit model presented in Table 2, we divided the ranked predicted probability values to generate six subsamples that were heterogeneous between groups but homogeneous within groups. These subsamples are referred to as strata one through six in Table 3. We divided the sample in descending order so that a higher stratum number indicates a higher likelihood of using social networks in the job search. Specifically, the probability that job seekers in the first stratum used their social networks in the job search process was the smallest-less than 0.1-and the number and proportion of job seekers who actually used social networks in this subsample was also the smallest, with only 84 out of 393 people using social networks. The probability of using a social network was slightly higher in the second stratum than in the first and ranged from 0.1 to 0.19. The number and proportion of job seekers who actually used social networks were also higher than those in the first stratum, with 124 out of 354 respondents using social networks. Finally, respondents in the sixth stratum had the highest probability of using a social network, with each person having a probability of more than 85%. The number and percentage of those who actually used their social networks were also the highest at 437 out of 589. Each column in Table 3 represents a stratum, and each row represents an independent variable that helps predict the likelihood of using a social network. Ideally, within each stratum of the subsample, the effects of each independent variable on the dependent variable would be statistically insignificant, which means that the use of social networks is not confounded by any other factor in the subsample and can be considered a purely exogenous variable. However, in practice, it is very difficult to obtain such a perfect match, and there are many cases where the individual variables are still significant. For example, the variable "paternal Party membership" in the fifth stratum has a p-value of 0.044, indicating that in this stratum, paternal Party membership still influences whether respondents use their social networks. As suggested by Xie and his colleagues [33,34], we need to further control for these still significant variables in the next step of the model when we predict the effect of social networks. After obtaining the six propensity score strata, we then calculated the effects of the use of social networks in each stratum and subsequently fit the relationship between the number of strata and the effects of social networks using VWLS. The difference between VWLS and OLS is that VWLS relaxed the assumption of homoskedasticity. In fact, the variances did vary across the different subsamples. In addition, we also found the average treatment effect for the overall sample, following the conventional method for propensity score matching. The final results of the analysis are presented in Table 4 and Table 5 . Turning first to Table 4, the table is divided into three panels. The top panel reports the coefficient, standard error, and Z value of the social network effect for each of the six subsamples. As the subsample ranking increased , the effect of social networks on earnings became progressively smaller and eventually become negative . It should be mentioned that because the subsamples in each stratum were created according to the empirical stratification results, the subsamples themselves were not representative, and the results for those subsamples were not generalizable to higher-level groups. In fact, this step is only an intermediate step in the entire analysis process, and the results are only meaningful after weighted summation as in propensity score stratified matching or regression fitting using variance weighting as in the SM model. The middle and bottom panels of Table 4 present the results of a composite analysis based on the effects of each stratum. The middle panel presents the calculated average earnings effect of social network use for the overall sample according to the propensity score subclassification method. b = ∑ K k=1 [ * b k ] Var = ∑ K k=1 [ˆ2) * Var] SE = Var Z = b/SE where b is the average effect of social network use, k = 1, 2, . . . , 6 indexes the number of strata, b k is the coefficient representing the effect of social network use on earnings in each stratum, n k is the number of observations in each stratum, N is the number of observations in the whole sample, and SE is the standard error of b. When the average treatment effect b is divided by its standard error, SE, the Z value used for statistical inference is obtained. In the overall sample, job seekers who use social networks had significantly higher earnings than those who do not , which is consistent with the findings of previous studies. The bottom panel of Table 4 shows the relationship between the social network earnings effect and the propensity to use social networks estimated via VWLS. The results indicate that there was a significantly negative relationship between the strata ranking and the social network effect. Table 5 is structured in the same way as Table 4. Looking at the top of the table reveals that within each subsample, the coefficient representing the effect of social network use on job satisfaction showed steadily increases. The results in the middle panel were calculated in the same way as the earnings effect and indicate that in the overall sample, there was no significant difference in job satisfaction between job seekers who use social networks and those who do not. The bottom panel of the table shows the relationship between the effect of social networks on job satisfaction and the propensity to use social networks obtained via VWLS. The results show that there was a significant positive effect between the strata ranking and the social network effect, and this effect was statistically significant. That is, the higher the propensity to use social networks when seeking employment, the higher the job satisfaction of job seekers. This result is the opposite of that for the earnings effect. --- Conclusions and Discussion The job search process for laborers is actually the process of allocating labor resources through the labor market. From the planned economy in China's pre-reform period to its dual-track system at the beginning of the reform and then into the era of the market economy as the reform deepened, resources have been allocated through three channels: redistribution, the market, and social networks [4,17,19,38]. Of these, redistribution channel and the market channel are formal channels for resource allocation, while the social network channel is an informal resource allocation channel. Theoretically, as marketization increases over time, market rules become increasingly clear, institutional rigidity becomes stronger, the power of formal channels increases, and the use of informal channels such as social networks should decrease. However, the most recent empirical data show that the proportion of workers using social networks during the job search process has increased to nearly 80% of the samples [39]. These realistic data suggest that the use of social networks in job searching is no longer restricted to a special group, and the internal heterogeneity within the group of social network users is gradually increasing [40]. This leads us to ask: for this internally heterogeneous group, is there also variability in the effect of social networks? That is, are the returns to social networks consistent across those job seekers who use them? Focusing on the use of and returns to social networks during job searching, this paper attempts to address the two-part endogeneity issue: First, the endogeneity in pretreatment effects, which means whether the use of social networks is a random event; second, the endogeneity in treatment effects, in this study meaning whether the return to social networks is consistent among those actors who use them when searching for a job. We employed a large set of survey data on social networks and used a heterogenous treatment effects model in our empirical analysis. We obtained the following main conclusions: First, the use of social networks in job searching is not random, and the propensity of job seekers with different characteristics to use social networks is not the same. In the process of job searching, which is an instrumental action, the choice of job seekers to use or not to use social networks is not a random event. Rather, there are certain characteristics that lead some people to use their social networks, while others choose not to. These characteristics are both individual and structural. Most previous research on social network effects has been based on analyses of regression models. Research based on OLS assumes that all the behaviors of the study occur randomly; however, the creation and the use of social networks-interactions among actors-is purposeful and highly subjective. It is difficult to satisfy the requirement of random distribution [22,23]. In our empirical analysis, we found that there do indeed exist some shared characteristics that result in essential differences between the two types of people: those who use social networks and those who do not. Second, the returns to social networks are different for job seekers with different propensities to use social networks. This means that in the labor market job search process, there are two different selection biases working at the same time: there is not only pretreatment heterogeneity, which means that the use of social networks suffers from selection bias, but also treatment effect heterogeneity, which means that the effects of social networks are also biased due to endogeneity. Even within the group of those who use their social networks when searching for a job, the returns to that use differ from person to person. Third, there is negative selection in the instrumental effect of social network use in the job search process but positive selection in the expressive effect: the higher the propensity to use one's networks, the lower the income return to social networks and the higher the job satisfaction; the lower the propensity to use one's networks, the higher the income return and the lower the job satisfaction. Endogeneity has been a major challenge in social network analysis in recent years, especially in research on social network effects in labor markets [22,23,41]. Scholars have tried to respond to this endogeneity challenge, which takes many forms, such as the homogeneity of social networks [24], the selectivity of social networks [12,13,37], and reverse causality [42]. Previous studies on social network effects have not found heterogeneous returns to the use of these networks, which may have been due to the limitations of their research methodology. This study identified endogeneity in both pretreatment effects and treatment effects and estimated the effect of social network use while considering the complete endogeneity problem. People differ not only in their use of social networks but also in how they are affected by that use. This study provides ideas for analyzing the heterogenous returns to social networks. We first estimated the probability of using social networks and then stratified the sample on this basis to calculate the effects of social networks among those with different propensities to use their social networks. Finally, we tested the relationship between the ranking of the strata and the effect of social network use. Nan Lin has reviewed 31 studies on the relationship between social capital and status attainment from the last two decades of the last century, and 30 of those studies demonstrated a link between social capital and status attainment [17]. Are these links the same for different actors? Nan Lin's strength-of-position proposition states that the better the initial position of an actor is, the more likely they are to access and mobilize higher levels of social capital. This study builds on this proposition and further explores the differences in returns related to different propensities. The results show that in a pyramidal social structure, there are not only differences in the distribution of resources but also differences in the returns to resources. --- Limitation This paper also has some limitations. In this study, we first explored the heterogeneity in the returns to social networks; however, more advanced research may be conducted in the future. In our exploration of the use of social networks, we used various external individual-level characteristics to comprehensively analyze the propensity to use social networks. We believe that a third dimension could be introduced in future research that enables an in-depth exploration of the relationship between group characteristics and the propensity to use social networks and the differences in the corresponding returns. For example, information about class [43], a concern of sociological research, could be included. Are there differences in the propensity of members of different classes to use their social networks, and are there differential returns? This would further enrich the social implications of social network research. Second, this study was concerned with the returns to social networks at the beginning of the job seeker's entry into their career. In addition to the role of social networks in the job search process, which is to help job seekers find jobs and earn high salaries, social networks may also have long-term effects and delayed returns. In the real labor market, job seekers' use of social networks to obtain jobs may not necessarily generate benefits at the beginning of their entry into the workforce. Whether those who find jobs through social networks are sheltered by that network after they enter their job, thus obtaining long-term professional development, rapid promotions, and job security, is an interesting question [44]. The collection of panel data will help us answer this question effectively. In addition, this study was concerned with the use of and returns to social networks in the labor market, and the labor market segmentation model is a classical theoretical model in labor market research. The object of analysis in this paper was the use of social networks in the labor market as a whole. A prominent feature of China's social development in the past 40 years since its reform and opening up is inequality. What kind of differences might exist in the use of and returns to social networks in different periods and regions? Whether institutional differences, industrial differences, and differences in occupational levels have caused labor market segmentation for different reasons and whether this segmentation has led to differences in the use of and returns to social networks are specific topics to be discussed in depth in future research. --- Data Availability Statement: The data presented in this study are available on reasonable request from the corresponding author. --- Author Contributions: Conceptualization, X.G.; data curation, Q.C.; formal analysis, Q.C.; funding acquisition, X.G.; investigation, X.G.; methodology, X.G. and Q.C.; project administration, X.G.; writing-original draft, X.G.; writing-review & editing, X.G. All authors have read and agreed to the published version of the manuscript.

With the advancement of social network research over time, a research consensus has been reached that the use of social networks in job searching can provide positive returns. This study focused on the heterogeneity in the returns to social networks. Using Job Search and Social Networks (JSNET) survey data on urban residents of China, we examined the differences in the propensity to use social networks in job searching and the returns to social networks in terms of job seekers' earnings and job satisfaction using propensity score stratification and the heterogeneous treatment effects model (HTE model). The use of social networks in job searching was found to be nonrandomly distributed, and the propensity to use such networks varied according to job seeker characteristics. For job seekers with different propensities, the returns to social networks were also different. Moreover, there was negative selection in the instrumental effect of social network use in the job search process but positive selection in the expressive effect: the higher the propensity to use one's networks, the lower the income return to social networks and the higher the job satisfaction; the lower the propensity to use one's networks, the higher the income return and the lower the job satisfaction.

IntrOduCtIOn Due to the rapidly ageing population and increasing longevity, in addition to increasing improvement in medical care, a growing number of people are living for long periods of time with chronic disease. The WHO reported that chronic diseases kill 40 million people per year, which is equivalent to 70% of all deaths globally. Each year, 15 million people die from a chronic disease, and >80% of these 'premature' deaths occur in low-income and middle-income countries. 1 In recent years, the number of individuals with chronic diseases in China has continued to rise, with many residents facing serious health challenges. There were 260 million people with chronic diseases in China in 2012, and this number has increased by an average of 8.9% each year. Deaths from chronic diseases account for 86.6% of total mortality. As a result of the rapidly ageing population, the number of elderly people in China in 2050 is predicted strengths and limitations of this study ► The China Health and Retirement Longitudinal Study is the first national survey focusing on middle-aged and elderly individuals, and provides detailed information about respondents and their living spouses. ► This was the first analysis of foregone care among Chinese middle-aged and elderly people with chronic diseases. ► This paper evaluated foregone care only among middle-aged and elderly adults who perceived a need for healthcare but did not seek treatment; however, it did not take into account those not perceiving the need for healthcare; therefore, the prevalence of foregone care may have been underestimated to some extent. ► Cross-sectional data cannot be used to draw causal conclusions. Open Access to total >400 million, accounting for one-third of the total population, and the average number of chronic diseases that individuals >60 years have is estimated at 2.2. China has entered a period of high economic burden caused by chronic diseases, which account for approximately 70% of the total economic disease burden. 2 According to a report by WHO in 2015, the direct medical costs for chronic diseases in China were >US$500 billion, and by 2030, rapid ageing may increase the financial burden of chronic diseases by 40%. Access to equitable healthcare, according to need, and regardless of demographic, ability to pay or social background, is an important goal for worldwide healthcare service systems. 3 China has implemented a series of healthcare reforms during the past two decades, including the expansion of health insurance coverage and the reformation of the health service system, with the ultimate goal of affordable and equitable healthcare for all. The reforms of the healthcare systems have minimal benefits at the beginning and progress with expanded benefits. 4 However, healthcare in China remains highly unequal across different subpopulations, and both the demand for, and inequality in, healthcare utilisation have increased significantly in this country, due to its rapidly ageing population. Several studies have addressed this issue by examining factors associated with healthcare utilisation among the elderly in China. [5][6][7][8] Foregone care is another aspect of healthcare access; an individual with forgone care needs is defined as one who does not use healthcare, despite perceiving a need for it. Forgone care is an important aspect in the assessment of healthcare system performance, as it represents the gap between the perceived need and actual utilisation of healthcare services from the citizens' perspective. Ageing is accompanied by an increase in the prevalence of non-communicable chronic diseases. 9 In China, the elderly people are more sensitive to the economic burden of diseases overall because of the high prevalence of chronic diseases and low incomes of this population, and the absence of social security mechanisms. 10 Thus, elderly individuals with chronic diseases may have a higher prevalence of foregone care compared with those who do not have such conditions. Several studies have empirically tested the associations between individual and community factors and foregone care. These studies indicate an association between higher rates of foregone care and female sex, younger age, rural living, lack of health insurance, lack of financial support, low levels of education and poor health. [11][12][13][14][15][16] Although foregone care is an area of high interest for researchers and policy-makers, there is a dearth of research on this subject among middle-aged and elderly individuals with chronic disease in China. The overall goal of this study was to identify the prevalence of foregone care and its associated factors among middle-aged and elderly people with chronic conditions. Two specific objectives were defined: comparison of the prevalence of foregone care between middle-aged and elderly individuals with and without chronic diseases and using Anderson's behavioural model, to identify factors associated with foregone care among middle-aged and elderly individuals with chronic diseases. --- MethOds And dAtA data source/sample This study was based on data from a nationally representative household survey of middle-aged and elderly people, the China Health and Retirement Longitudinal Study . CHARLS is a biennial survey conducted by the China Centre for Economic Research at Peking University. The sample was drawn in four stages. First, county-level units were sampled directly. These counties cover 28 of 30 provinces in mainland China, other than Tibet. Second, village and community units within county units were chosen with the help of the National Bureau of Statistics, using recently updated village-level population data. The sample used administrative villages in rural areas and neighbourhoods in urban areas as primary sampling units . Three PSUs were selected within each county-level unit, using probability proportional to size sampling, to select a total of 450 PSUs. Third, household units were selected in each PSU. The sampling frame was constructed using Google Earth base maps, and a computer-assisted personal interview programme was then used to sample households and to conduct the interviews using laptops. Finally, all age-eligible sample households who were willing to participate in the survey were interviewed. CHARLS baseline data include detailed information about respondents and their living spouses. The main questionnaire includes information on basic demographics, family, health status and functioning, healthcare and insurance, work, retirement and pension, income, expenditure and assets. In the 2013 wave, the survey sample consisted of 18 605 individuals ≥45 years old and their spouses. In this paper, we excluded spouses ≤45 years old, and the remaining 18 377 observations were included in the analysis. statistical analysis Binary multivariate logistic regression was applied to estimate ORs of foregone care. The dependent variable 'foregone care' was dichotomised into 0 = 'reported utilisation of healthcare' and 1 = 'reported non-use of healthcare'. All explanatory variables were recorded as binary variables. --- Variable selection The dependent variables were three kinds of foregone care: non-use of outpatient services, non-use of inpatient services and non-attendance for physical examination. Participants were asked the following two questions: 'Have you been ill in the last month?' and 'What was the main reason for not seeking outpatient treatment?", and Open Access the responses were used to estimate 'non-use of outpatient services' . Participants were asked, 'In the past year, did a doctor suggest that you needed inpatient care but you did not get hospitalised?' and the response was used to estimate 'non-use of inpatient services' . Participants were asked, 'Did you undergo a physical examination in the last 2 years?' and the response used to estimate 'non-use of physical examination' . Independent variables were selected based on Andersen's healthcare utilisation model . This model has guided systematic investigations into the factors that can lead to the use of healthcare services, including predisposing, enabling and need factors. 17 Predisposing factors include demographic characteristics and both social structure and health belief-related factors. In our analyses, we included sex, age and marital status as demographic characteristics and education, employment status and family size as social structure factors. Enabling factors are those that make health service resources available to an individual; they can be measured by determination of family attributes, such as income, access to health insurance or other sources of third-party payment. Enabling factors in the community in which the family lives can also affect the use of services. Community attributes include the number of healthcare facilities and personnel in a community and the region of the country, in addition to the rural-urban nature of the community. In our analyses, access to public insurance, income levels and financial transfers received and given were considered as family components, while area of residence and medical facilities were considered indicators of community attributes. Need factors were both perceived need and need diagnosed or evaluated by a healthcare professional; the former was based on self-reported health status, and the latter included chronic diseases, depression, body mass index and limitations on activities of daily living . Variables included in the multivariate model are presented in table 1. --- results sample characteristics The total sample consisted of 18 377 respondents ≥45 years old. Missing data were automatically removed during data processing. No chronic disease was reported by 28.88% of respondents, with 71.12% reporting ≥1 chronic disease. In CHARLS, the chronic conditions included hypertension, dyslipidaemia, diabetes, cancer, chronic lung, stomach, memory-related, and/or liver diseases, heart problems, stroke, kidney, emotional and nervous problems, arthritis or rheumatism and/or asthma. Patients with chronic diseases were divided into two categories, including individuals with one chronic and those with multiple chronic diseases in one person. Descriptive statistics of the characteristics of the individuals with, versus without, chronic conditions are presented in table 2. Chronic disease prevalence was slightly higher among middle-aged and elderly women than men. Middle-aged and elderly individuals aged 45-55 years accounted for 43.28% of those without chronic disease, which was higher than the proportion of those with one or multiple chronic diseases; however, with increasing age, the proportion of individuals with one or multiple chronic diseases exceeded that of people without these conditions, indicating that the risk of chronic disease increases with age. The proportion of people without chronic diseases, and with one or multiple chronic diseases gradually increased among middle-aged and elderly people who were divorced/ single/separated or unemployed/retired, indicating that the risk of chronic disease was relatively high among this group. Middle-aged and elderly people with lower educational levels and small family size also had a higher risk of chronic diseases. Regarding enabling factors, the ratios of population subgroups with social health insurance did not differ significantly. The ¥1496-8126 income group had the highest probability of having more than two types of chronic disease, and the proportion of people without chronic disease was greater in the high-income, compared with the low-income, group. Compared with middleaged and elderly people who did not receive support from others, people with economic support exhibited an increasing trend towards lack of chronic disease, 73.75% towards one chronic disease and 78.14% towards multiple chronic diseases; people who provided economic support to others exhibited the opposite trend. Among need factors, middle-aged and elderly individuals whose self-reported health was fair or poor had an increasing trend towards having no chronic disease , one or multiple chronic diseases, and those whose self-reported health was good or excellent exhibited the opposite trend. These results indicate that the risk of chronic disease was negatively associated with health status. Depression and probable depression were also associated with a significant increasing trend towards having one or more chronic diseases. There was also an increasing trend in probability from people without chronic disease, to one chronic, and then to multiple chronic diseases among middle-aged and elderly people with BMI >24 or with any ADL. --- Prevalence of foregone care The data presented in table 3 demonstrate the prevalence of foregone care among middle-aged and elderly individuals. Overall, the prevalence of non-use but oughtto-have-used outpatient services within the last 4 weeks was 10.21%, and the prevalence of non-use of inpatient services was 6.84%. Comparisons of foregone care among Open Access different groups demonstrated that the underutilisation rate was higher among people with multiple chronic diseases. Furthermore, the results demonstrate that individuals without chronic disease had the highest probability of not having undergone a physical examination in the last 2 years. --- Multivariate regression analysis Binary logistic models were constructed to examine the determinants of foregone care among middle-aged and elderly Chinese people with chronic diseases. Estimated coefficients describing the predicted effects of the variables are presented in table 4. We also calculated overall significance values for a multivariate logistic regression Open Access With the exception of sex, all other predisposing factors were predicted to have significant impacts on foregone healthcare. Specifically, middle-aged and elderly people >55 years old were less likely to report outpatient or physical examination foregone care compared with those <55 years old. Individuals who were married or had a larger family had a higher likelihood of foregone physical examination, while those with high levels of education had a significantly lower likelihood of foregone physical examination. Middle-aged and elderly people with chronic diseases who were retired without pensions exhibited a higher likelihood of outpatient and inpatient foregone care compared with retired people with pensions. Open Access --- Open Access Among enabling factors, we found a significant association between social health insurance and non-use of outpatient and inpatient services; hence, enrolment in social health insurance schemes may significantly reduce the likelihood of outpatient and inpatient foregone care among middle-aged and elderly people with chronic diseases. The highest income group demonstrated a significantly reduced likelihood of forgone inpatient and physical examination care compared with the lowest income group. Receipt of financial transfers increased the likelihood of non-use of outpatient services, and providing transfers was associated with reduced probability of foregone physical examination. Compared with middle-aged and elderly people living in urban areas, those in rural areas were significantly more likely to forego outpatient and physical examination care. Among need factors, significant associations were detected between self-reported health, multiple chronic diseases, depression, and outpatient, inpatient, and physical examination foregone care. Middle-aged and elderly people with chronic diseases with fair, good or very good self-reported health had a lower likelihood of outpatient and inpatient foregone care compared with those with poor health status, and the likelihood decreased with increasing health status; however, individuals who self-reported their health as fair had a higher likelihood of foregone physical examination. Middle-aged and elderly people who had multiple chronic diseases demonstrated a higher probability of foregone outpatient and inpatient care, while exhibiting a lower likelihood of foregone physical examination. Individuals with depression had a higher likelihood of outpatient, inpatient and physical examination foregone care. Middleaged and elderly people with BMI values >24 had a lower probability of outpatient and inpatient foregone care. Any ADL increased the possibility of outpatient service foregone care. Drinking alcohol did not have a significant impact on any kind of foregone care, while smoking significantly increased the likelihood of foregone physical examination. dIsCussIOn Along with the rapidly ageing population in China, the number of chronic diseases continues to rise and the elderly face serious health challenges. Although many studies have analysed healthcare utilisation in diverse population groups, few have examined foregone care in middle-aged and elderly chronically ill Chinese patients. This study, focusing on middle-aged and elderly people, was performed to analyse the prevalence of foregone healthcare and its associated factors in China. In this study, we found that 10.21% and 6.84% of respondents had foregone outpatient and inpatient care, respectively; however, the prevalence of physical examination foregone care was relatively high . This may be attributable to the fact that Chinese social healthcare insurance schemes do not cover physical examinations; therefore, many middle-aged and elderly people are apt to forego physical examinations because of the associated economic burden. The prevalence of outpatient and inpatient foregone care rose, alongside increasing number of chronic diseases. Furthermore, the results of regression analysis confirmed that respondents with multiple chronic diseases were more likely to forego outpatient and inpatient care. These data indicate that a greater demand for health services is associated with a higher probability of foregone outpatient and inpatient care. However, the likelihood of physical examination foregone care exhibited the opposite trend; people without chronic disease were most likely to forego physical examination and the prevalence decreased with increased number of chronic diseases. This result suggests that middle-aged and elderly individuals with chronic disease may have stronger awareness of preventative healthcare. Among predisposing factors, our results indicate that the possibility of foregone outpatient and physical examination care decreases with increasing age. This is consistent with previous results literature reports. 11 18 People in older age groups generally have more need for healthcare, related to more serious conditions, and may be more flexible with their time when seeking healthcare compared Open Access with younger individuals. Middle-aged and elderly people with chronic diseases who have fixed incomes accessed more healthcare and exhibited a relatively low likelihood of foregoing care. This finding indicates that some medical financial assistance programmes may need to be extended, particularly with respect to unemployed and elderly retired people without pensions, to facilitate further reduction of the possibility of foregone care. In addition, our analyses revealed that middle-aged and elderly people with chronic diseases who were married and had large families exhibited a relatively high probability of foregone physical examination, consistent with a number of existing literature reports. 19 We did not identify any association between sex and foregone care, which is also in line with several previous publications. 12 20 Of enabling factors, our results demonstrate a strong association between socioeconomic variation and foregone care. Specifically, we found a significant association between household income level and foregone care; people with chronic diseases in the highest income group reported less foregone inpatient and physical examination care compared with those in the lowest income group; however, we did not find a significant association between income level and outpatient foregone care, similar to previous studies. 11 16 18 These findings indicate that due to higher hospitalisation costs, income levels remain an important impact factor influencing the possibility of inpatient foregone care; however, for outpatient services, there were no significant differences in the likelihood of foregone care among different income groups, indicating that the universal coverage of medical insurance in China may be gradually improving the equity of outpatient care utilisation among middleaged and elderly people with chronic disease from different income levels. We also found that although social healthcare insurance can significantly reduce the level of outpatient and inpatient foregone care among chronically ill elderly patients, these schemes may not significantly impact physical examination foregone care among elderly patients with chronic disease. Hence, policy efforts may need to focus on chronic elderly patients having urban resident medical insurance or new cooperative medical insurance, and strategies may need to be adjusted to promote the effective utilisation of preventive healthcare. Middle-aged and elderly people with chronic diseases who have received financial transfers from others exhibited a slightly higher likelihood of outpatient foregone care, while those who had made transfers to others had a significantly lower level of physical examination foregone care. Residents in rural areas had a significantly higher likelihood of outpatient and physical examination foregone care, as previously described. 21 These findings may reflect the rural-urban income gap and differences in medical security in China. As Andersen described, need factors best describe the true needs for healthcare. 17 Consistent with previous studies, we found that middle-aged and elderly people with multiple chronic diseases or depression were more likely to forego outpatient and inpatient care. 8 22 23 This may be because of high demands for medical services or lack of patient compliance among this group, likely leading to a relatively high probability of foregone care. Regarding physical examinations, multiple chronic diseases were associated with a reduced possibility of foregone care; however, depression was associated with an increased likelihood, consistent with published data. 8 24-27 Self-reported health was negatively associated with outpatient and inpatient foregone care, except for individuals whose self-reported health was excellent. This indicates that the superior health of respondents was associated with a lower likelihood of foregone care. 28 ADL limitations did not affect inpatient and physical examination foregone care; however, these factors significantly increased the likelihood of outpatient foregone care. This finding maybe related to the fact that people with ADL often have some difficulty seeking outpatient treatment in a timely manner. 29 The findings of this study may provide evidence on healthcare underutilisation and associated factors among middle-aged and elderly people. Some limitations of our study must be acknowledged. We evaluated foregone care only among middle-aged and elderly adults who perceived a need for healthcare but did not seek treatment; however, we did not take into account those who did not perceive the need for healthcare. Some patients objectively require healthcare, but do not perceive that need; therefore, the prevalence of foregone care may have been underestimated to some extent. In addition, cross-sectional data cannot be used to draw any causal conclusions about why these individuals may have foregone care. --- COnClusIOn Our findings reveal that the prevalence of foregone physical examination is relatively high among middle-aged and elderly people, and that this prevalence decreases with an increased number of chronic diseases. As a result of their greater demand for health services, respondents with chronic diseases demonstrated relatively higher likelihoods of both outpatient and inpatient foregone care. Hence, the adjustment of health insurance policies and improvements in the hierarchical medical system in China may be helpful to the effective utilisation of preventive care and outpatient and inpatient services. Some predisposing factors, including age, marital status, employment, education and family size; enabling factors, including social health insurance, income level and area of residence; and need factors, such as self-reported health, multiple chronic diseases and ADL, significantly affected foregone care among middle-aged and elderly people. Therefore, we may need to address these socioeconomic and demographic factors for reducing foregone care and enhancing the effective use of health services among Open Access middle-aged and elderly people in China. Finally, further work, including longitudinal studies, is required to gain a better understanding of the causal relationships between foregone care and its associated factors. --- The study was approved by the ethics committee of Nanjing Medical University; reference number: 2017613. Provenance and peer review Not commissioned; externally peer reviewed. data sharing statement Extra data can be accessed via the Dryad data repository at http:// datadryad. org/ with the

Objective In general, published studies analyse healthcare utilisation, rather than foregone care, among different population groups. The assessment of forgone care as an aspect of healthcare system performance is important because it indicates the gap between perceived need and actual utilisation of healthcare services. This study focused on a specific vulnerable group, middle-aged and elderly people with chronic diseases, and evaluated the prevalence of foregone care and associated factors among this population in China. Methods Data were obtained from a nationally representative household survey of middle-aged and elderly individuals (≥45 years), the China Health and Retirement Longitudinal Study, which was conducted by the National School of Development of Peking University in 2013. Descriptive statistics were used to analyse sample characteristics and the prevalence of foregone care. Andersen's healthcare utilisation and binary logistic models were used to evaluate the determinants of foregone care among middle-aged and elderly individuals with chronic diseases. results The prevalence of foregone outpatient and inpatient care among middle-aged and elderly people was 10.21% and 6.84%, respectively, whereas the prevalence of foregone care for physical examinations was relatively high (57.88%). Predisposing factors, including age, marital status, employment, education and family size, significantly affected foregone care in this population. Regarding enabling factors, individuals in the highest income group reported less foregone inpatient care or physical examinations compared with those in the lowest income group. Social healthcare insurance could significantly reduce foregone care in outpatient and inpatient situations; however, these schemes (except for urban employee medical insurance) did not appear to have a significant impact on foregone care involving physical examinations. Conclusion In China, policy-makers may need to further adjust healthcare policies, such as health insurance schemes, and improve the hierarchical medical system, to promote reduction in foregone care and effective utilisation of health services.

Introduction Background. Explanations for monogamous marriage have centered around the prevalence of this practice in Eurasia , linking its emergence to the development of idiosyncratic features of societies in the region. These include, for example, the establishment of large nation states and democracy ; the spread of Christianity ); the onset of industrialization and urbanization , and of economic development more generally . Consistently, cross-cultural analyses show that societies scoring high on scales measuring "societal complexity" tend toward monogamous marriage . By focusing on the cross-cultural distribution of marriage strategies, these studies fail to account for their history. Restrictions on polygynous marriage appear in the earliest historical records, long predating the development of aspects of social organization typically associated with Eurasian societies and with "societal complexity" and "modernization" more generally . In this paper I reconstruct the pattern of change in marriage strategies in the history of societies speaking Indo-European languages, using cross-cultural data in the systematic and explicitly historical framework afforded by the phylogenetic comparative approach . In the companion paper I extend this framework to reconstructing the history of residence strategies in the same set of societies . Finally, this framework is extended in Fortunato to investigate the co-evolution of monogamous marriage and neolocal residence; on this analysis, it cannot be excluded that the observed association between marriage and residence strategies is the artifact of a history of descent of these societies from a common ancestor. Phylogenetic tree-building analyses of linguistic data support Renfrew's hypothesis for the origin of the IE language family, which envisages an expansion from Anatolia with the spread of agriculture starting between 7000 and 6000 BCE . This scenario involves an early split of IE languages from their sister group, the extinct Anatolian family, which comprises the extinct languages Hittite, Palaic, Lydian, Luwian, and Lycian; together, IE and Anatolian form the Indo-Hittite language family . The other main competing hypothesis, proposed by Gimbutas , places the homeland of the language family in the Pontic steppes north of the Black Sea and posits an expansion driven by nomadic horse-riding pastoralists starting after 4000 BCE . Consistent with the former scenario, I use the terms "Proto-Indo-European" for the hypothetical ancestor of IE languages and "Proto-Indo-Hittite" for the hypothetical ancestor of Indo-Hittite languages, as well as for the hypothetical "proto-societies" that spoke them. Other classifications, based on alternative explanations for the origin of the IE language family, use PIE for the ancestor of IE and Anatolian languages . To avoid confusion, throughout this and the companion paper I have changed instances of the latter usage to the one stated here. --- Related Research. Early IE marriage strategies have been reconstructed on the basis of linguistic and ethnographic evidence. The linguistic evidence is, at best, tenuous. The correspondence of the Middle Irish and Avestan terms for "concubine, wanton woman" suggests that PIH society recognized some form of polygynous mating, if not polygynous marriage; this interpretation is supported by the use of specialized terms to designate legitimate children . A second line of evidence relates to the concept of widowhood: while it is possible to reconstruct a PIH term for "widow," there is no corresponding term for "widower." One interpretation of this pattern is that male widowhood was not recognized in PIH society because men married polygynously, such that the death of one wife did not affect their marital status . Implicit in this interpretation are, however, a number of unrealistic assumptions, for example that all PIH men married multiple wives and that they rarely, if ever, outlived their wives; both represent demographic impossibilities. Based on the ethnographic evidence, Murdock reconstructed "an Eskimo type of social structure in the prehistory of the Indo-European peoples." The defining features of this type of social organization are the presence of the Eskimo system of cousin terminology and the absence of exogamous unilineal kin groups; additional typical characteristics include the presence of monogamy, independent nuclear families, and neolocality, but variant sub-types characterized by non-neolocal marital residence may feature polygyny and extended families . In the Eskimo type of cousin terminology all cousins are equated with each other but differentiated from siblings; unilineality refers to kin groups organized around principles of matri-or patrilineal descent; neolocality indicates residence of married couples apart from the kin of either spouse. The reconstruction was inferred from the social organization of five societies speaking IE languages, representing four of the major sub-groups of the language family. Specifically, the social systems of Yankees and Ruthenians are of the Eskimo type, the social systems of Albanians and Ossets include features suggesting "Eskimo antecedents," while the social system of the Kurds is not incompatible with the Eskimo type. Quite apart from the small number of societies upon which the reconstruction was based, Murdock's approach presents a serious methodological issue. According to Fox , modern IE terminologies for kin and affines tend to show a much stronger bias toward the nuclear family than was the case for early IE terminological systems. This brings into question the validity of inferences about past social organization drawn from kinship and affinal terminologies . Finally, Fortunato and Mace used the ethnographic evidence in a phylogenetic comparative framework to test the hypothesis of co-evolution of bridewealth with polygyny and of dowry with monogamy in a sample of 51 societies speaking IE languages. This analysis reconstructed monogamy with dowry as the most likely state at the root of a phylogenetic tree representing the historical relationships among the 51 societies; in addition, the tree included Hittite, thus the root of the tree corresponded to PIH. The reconstruction was obtained using the maximumlikelihood phylogenetic comparative method developed by Pagel and implemented in Discrete ; this method estimates the evolutionary scenario that is most likely to have produced the observed distribution of states of the two traits across taxa at the tips of the tree. The tree was generated through phylogenetic tree-building analysis of the corresponding 51 speech varieties in Dyen et al.'s IE basic vocabulary database, using a maximum-parsimony optimality criterion, as implemented in PAUP* 4.0b4a ; this approach finds the tree or set of trees that optimizes the degree of fit to the data. However, the use of a "best" tree for phylogenetic comparative analysis is problematic, because results are affected by the topology and other parameters of the tree used . Thus, while controlling for the effect of descent on the distribution of cultural practices, Fortunato and Mace's reconstruction may be contingent upon the phylogenetic tree model used to represent how the societies are related. --- Rationale and Objective. For the most part, previous attempts to infer early IE marriage strategies from linguistic and ethnographic data have failed to use a systematic and explicitly historical approach. Where such an approach has been taken, the available methods did not account for uncertainty in the phylogenetic tree model used to represent population history. Here I use a phylogenetic comparative method, in a Bayesian reversible jump Markov chain Monte Carlo framework, to reconstruct the pattern of change in marriage strategies in the history of societies speaking IE languages. Using a phylogenetic tree to represent how the taxa are related, phylogenetic comparative methods infer likely evolutionary scenarios that produced the observed distribution of the attribute of interest across the taxa. The Bayesian MCMC framework uses a single tree or a sample of trees to represent the relationships among the taxa; use of a tree sample removes dependence of the inferences upon any single phylogenetic hypothesis. This is particularly important for application of the phylogenetic approach to crosscultural data, because the reticulate nature of the interactions linking human societies cannot be captured by any single tree model . In a similar way, the RJ-MCMC implementation of the approach removes dependence of the inferences upon any single model of trait evolution; the model of trait evolution specifies, for example, whether a trait is likely to be acquired and lost at the same or at different rates. This is also crucial in the analysis of cultural traits, because the mechanisms of change are usually unknown for these traits. More generally, the Bayesian MCMC framework estimates the degree of statistical uncertainty in the parameters of interest to the comparative question ; this provides an indication of the degree of confidence that can be placed in any particular inference about the evolution of the trait. A non-technical introduction to the approach is presented in Fortunato . Phylogenetic comparative methods assume that traits are transmitted vertically ; consequently, high rates of horizontal transmission of traits across societies may invalidate their application to cross-cultural data . Recent simulation analyses show, however, that phylogenetic comparative methods outperform non-phylogenetic methods under a wide range of simulated scenarios and levels of horizontal transmission . In any case, kinship and marriage systems appear to be "conservative" features of social organization ; in the context of linguistic and genetic variation, the effect of descent is strongest at the supra-regional level, while the effect of contact prevails within regions . This makes traits relating to kinship and marriage systems especially suited for analysis within the phylogenetic comparative framework. --- Data and Methods I used data on marriage strategy from the Ethnographic Atlas for a sample of societies speaking IE languages. The cross-cultural data were mapped onto a sample of trees representing how the societies are related, obtained by Pagel et al. through tree-building analysis of Dyen et al.'s IE basic vocabulary database. Finally, on the cross-cultural data and tree sample I used the phylogenetic comparative method developed by Pagel and colleagues to reconstruct ancestral states of marriage strategy. Cross-Cultural Data. The EA is distributed in electronic form through the World Cultures journal. Variable identifiers in this section follow Gray's EA codebook. The data in binary form are in the supporting information file; a map of their geographical distribution is in Figure 1. The cross-cultural sample was collated by matching societies in the EA with speech varieties in Dyen et al.'s IE basic vocabulary database, as described in the SI file. I coded societies included in the cross-cultural sample as monogamous or polygynous based on EA variable 9, which scores societies on the prevailing form of family organization . I collapsed the five categories for polygynous marriage, thus ignoring the distinction between limited and general polygyny, between general polygyny with sororal and non-sororal co-wives, and between general polygyny with co-wives occupying the same or distinct dwellings. This produced a sample with 18 of 27 societies coded as monogamous and 9 coded as polygynous . Tree Sample. I used Pagel et al.'s posterior probability sample of 750 phylogenetic trees to represent how societies in the cross-cultural sample are related by way of descent from a common ancestor. Trees are present in the sample in proportion to their posterior probability, which is the probability of the tree conditional on the data and model of word evolution used in the tree-building analysis, and can be interpreted as the probability that the tree is correct . For example, the Ibero-Romance speech varieties included in the tree-building analysis by Pagel et al. share an ancestor in 84% of the trees in the sample; the probability that they are a "monophyletic" group is thus 0.84, given the data and model of word evolution used in the tree-building analysis. As discussed below, use of a tree sample instead of a single "best" tree amounts to incorporating phylogenetic uncertainty in the comparative analysis; the degree of phylogenetic uncertainty at several of the nodes in the Pagel et al. tree sample emphasizes the importance of doing so in this case . Pagel et al. inferred the posterior probability distribution of trees from Dyen et al.'s IE basic vocabulary database, using the Bayesian MCMC phylogenetic tree-building method developed by Pagel and Meade , as described in the SI file. I obtained the tree sample from Mark Pagel. I pruned the trees to retain only the speech varieties corresponding to the 27 societies in the cross-cultural sample, plus the outgroup Hittite, using Andrew Meade's program BayesTrees . "Outgroup" taxa provide information on the direction of change in the data by virtue of being distantly related to the groups under investigation, the "ingroup" taxa; they are used in tree-building for 1 in the SI file. Colors express the marriage strategy , as per Figure 4; numbers correspond to taxa in Figure 4 and to entries in the relevant column in Table 1 in the SI file. determining ancestor-descendant relationships . I preferred this "pruning" strategy, over the alternative of generating a tree sample for the speech varieties included in the comparative analysis , because the accuracy of phylogenetic tree-building grows with increased sampling of taxa . Hittite was retained for consistency with previous work but was assigned no marriage strategy data for the purpose of the comparative analysis. Comparative Analysis. Reconstruction of ancestral states using the phylogenetic comparative method developed by Pagel and colleagues is performed using BayesMultistate, available as part of the BayesTraits package from http://www.evolution.rdg.ac.uk/BayesTraits.html. Unless otherwise specified, the information in this section is based on Pagel andMeade , Pagel et al. , and on the BayesTraits manual , to which I refer the reader for a more detailed description of the method and its application. A non-technical discussion of the method is in the SI file. Given the cross-cultural data and tree sample, BayesMultistate uses parameters q MP and q PM to describe the evolution of the trait "marriage strategy" on a tree. q MP and q PM measure the instantaneous rates of change, respectively, from monogamy to polygyny and from polygyny to monogamy ; they are used to define the probabilities of these changes, the probabilities of the two states at internal nodes on the tree, and the likelihood of the data, which is the probability of the data given the tree and the model of trait evolution specified by the rates ). In the likelihood calculations BayesMultistate treats taxa that are not assigned comparative data, like the outgroup Hittite in this case, as taking any state with equal probability. In Bayesian RJ-MCMC mode, BayesMultistate uses RJ-MCMC methods to estimate the posterior probability distributions of rate parameters and of ancestral states at internal nodes on a tree, and of the possible models of trait evolution specified by the rate parameters . Four model categories are possible in this case: that q MP and q PM take distinct positive values, that they take the same positive value, or that either one is set to zero while the other takes a positive value. The posterior probability of a parameter value is a quantity proportional to its likelihood of having produced the observed data and represents the probability of the parameter value given the data and model of trait evolution. Schematically, the posterior probability distributions are estimated by running RJ-MCMC chains that sample states in the model of trait evolution in proportion to their posterior probability, across trees in the tree sample; a state in the model consists of model category and values of the rate parameters and ancestral state probabilities. Combining estimates over the sample produced by a chain amounts to "averaging" inferences over uncertainty in the phylogeny, in the parameters of the model of trait evolution, and in the model itself. I performed five sets of analyses, each comprising five separate chains started from random seeds. One set estimated the posterior probability distributions of states M and P at internal nodes on the consensus tree summarizing the tree sample. The means of the posterior probability distributions of states M and P at a given node, denoted p and p, are multiplied by the posterior probability of the node itself, denoted p, to produce the combined probabilities of the two states at the node, denoted p and p; p ϩ p ϭ 1, thus p ϩ p ϭ p. This means that if reconstruction of the node itself is uncertain [i.e., if p Ͻ 1], the value of p sets an upper limit to the confidence that can be placed in the ancestral state reconstructions for the node. As a rule of thumb, confidence can be placed in reconstructions with combined probabilities Ն0.70. The other four sets of analyses were used to assess explicitly the relative "fit" of states M and P at nodes PIH and PIE. For each node, one set of analyses was run with the node fixed to state M and one with the node fixed to state P. The posterior probability distributions of log e values sampled by the chains reflect how well a given fossil state fits the node; a measure called the "Bayes factor," which is used to compare posterior probability distributions , provides an indication of the strength of the evidence in favor of one state over the other at the node. The Bayes factor for state M over state P is denoted B MP . 2log e is approximated as twice the difference between log e [H] for a chain fixed on state M and log e [H] for a chain fixed on state P, where log e [H] is the natural logarithm of the harmonic mean of the likelihood values. In theory, values of 2log e Ͼ 0 represent evidence for state M and values of 2log e Ͻ 0 evidence for state P. Specifically, the evidence for a given state is "weak" for 0 Ͻ ͉ 2log e ͉ Ͻ 2, "positive" for 2 Ͻ ͉ 2log e ͉ Ͻ 5, "strong" for 5 Ͻ ͉ 2log e ͉ Ͻ 10, "very strong" for ͉ 2log e ͉ Ͼ 10 . In practice, however, the harmonic means of likelihood values may vary across runs: they are expected to converge to the same value if the chains are run to infinity. Consequently, I take the conservative approach recommended by Pagel and Meade , which disregards any evidence for either state given by ͉ 2log e ͉ Ͻ 2. I determined the RJ-MCMC chain specifications through preliminary maximum-likelihood and MCMC runs, all with nodes not fossilized. These specifications ensure that the RJ-MCMC chains sample parameter space adequately and ultimately converge to the posterior probability distribution of states in the model of trait evolution. I ran the RJ-MCMC chains for 10 8 iterations, sampling every 10 3 , with an additional burn-in of 10 6 , and rate deviation set to 50. All chains used a uniform prior on the models and an exponential prior on the rate parameters; the mean of the exponential prior was seeded from a uniform hyperprior on the interval 0 -10. The shape of the prior distribution and the interval of the hyperprior only marginally affected the mean of the posterior probability distributions of log e values and of ancestral states, returning qualitatively similar results. For each set of analyses, convergence to the posterior probability distribution of states in the model of trait evolution was assessed by comparing the samples returned by the separate chains, through visual inspection of time-series plots of log e values, the posterior probability distributions of model categories, and the average deviation of parameter estimates across runs. The near-independence of sampling events was judged from the autocorrelation of the log e values of successive states sampled by the chains. In all cases, these diagnostics indicated that the chains sampled the target distributions adequately. --- Results For each set of analyses, I compared the log e [H] values for the states in the model of trait evolution sampled by the separate chains at a. "Z" denotes rates assigned to the zero class. "0" and "1" denote two distinct non-zero rate classes; rates with the same value are assigned to the same non-zero rate class. For example, under model category 1 q MP and q PM are assigned to the same non-zero rate class, that is, they take the same positive value; under model category 2 q MP is assigned to the zero rate class, that is, it is set to zero, while q PM is assigned to a non-zero rate class, that is, it takes a positive value; under model category 3 q MP and q PM are assigned to distinct non-zero rate classes, that is, they take different positive values. b. The relative cumulative frequency of a model category is obtained by summing the absolute frequency of sampled points in the model category to the absolute frequencies of sampled points in all preceding categories, if any, and then dividing by the total number of sampled points in all categories ͓e.g. /10 5 ϭ 0.993 for model category 2͔. convergence; I present results for the chain that returned the median value of the log e [H]. Below I discuss the ancestral state estimation at nodes on the consensus tree. The fossilization of nodes PIH and PIE largely confirms the ancestral state estimation and is discussed in the SI file. --- Estimation of Ancestral States on the Consensus Tree. At convergence, the chain sampled states in the model of trait evolution with mean log e Ϯ SD ϭ Ϫ11.43 Ϯ 0.93 . Below I example, q MP and q PM were assigned to the same rate class in 87.8% of the 10 5 sampled points . Over the four model categories, rates were assigned to 1.01 Ϯ 0.08 non-zero classes ; this indicates that the evolutionary transitions that produced the observed distribution of states of marriage strategy across societies in the sample can be described by a simple model of trait evolution based on only one non-zero rate class . Nodes PIH and PIE reconstructed as monogamy with high posterior probabilities under model categories 1, 3, and 4, and as polygyny with p ϭ 1 under model category 2 . In the latter category, transitions from monogamy to polygyny are excluded, because q MP is set to zero . This forces nodes PIH and PIE to reconstruct as polygyny: under this category, any variation in states of marriage strategy at the tips of the tree is the result of transitions from polygyny to monogamy. In other words, the presence of polygyny at the tips could not be accounted for if PIH and/or PIE reconstructed as monogamy. However, models in category 2 returned a mean log e value 1.67 units worse than models in the category that returned the best mean log e value , and 1.47 units worse than the mean log e value over the four model categories. This suggests that the evolutionary scenario described by model category 2 is unlikely to have produced the observed distribution of states of marriage strategy across societies in the sample. Posterior Probability Distributions of Ancestral States. Over the four model categories, nodes PIH and PIE reconstructed as monogamy with high posterior probabilities . The posterior probability distribution is more strongly skewed toward high values for state M at node PIE, as reflected in the higher value of p at this node . Monogamy reconstructed with high posterior probabilities through to nodes A and B on the consensus tree summarizing the tree sample, but phylogenetic uncertainty limits the confidence that can be placed in these inferences . Node D and node F reconstructed as monogamy with high posterior probabilities. Node E reconstructed as polygyny with high posterior probability. The uncertainty in the reconstructions at the base of the consensus tree means that a host of scenarios can explain the distribution of states of marriage strategy at the tips . Polygyny was acquired at least once on the tree, between nodes PIE and E, and possibly a second time in the branch leading to Albanian G. A minimum of two reversals to monogamy occurred, one in the branch leading to Panjabi ST and one in the branch leading to Singhalese. --- Discussion The phylogenetic comparative analysis of marriage strategies across societies speaking IE languages provides evidence in support of PIE monogamy; this pattern likely extended back to PIH, but the evidence is only suggestive. Polygyny evolved at least once, possibly twice, throughout the history of IE-speaking societies, but uncertainty in some of the "deep" reconstructions means that alternative evolutionary scenarios cannot be excluded. This uncertainty emphasizes the need for an explicitly historical approach when deriving inferences about past social organization from cross-cultural data, and to cross-cultural comparison more generally. In turn, the uncertainty in the phylogenetic model used to represent how the societies are related by descent stresses the importance of avoiding "best tree" approaches in phylogenetic comparative analysis. As discussed above, Fortunato and Mace used a "best" tree in the phylogenetic comparative analysis of marriage strategies and strategies of wealth transfer at marriage in IE-speaking societies. The present findings suggest that their reconstruction of PIH monogamy is not contingent upon the phylogenetic tree used. Further, while the outgroup Hittite was not assigned marriage strategy data in the present analysis, it was coded as monogamous in Fortunato and Mace's ; this was necessary because the phylogenetic comparative method they used did not allow missing data . The present findings indicate that the reconstruction by Fortunato and Mace is not contingent upon the state they assigned to the outgroup. Applying a phylogenetic comparative approach to the marriage transfer strategy data, in a Bayesian MCMC framework, Fortunato et al. showed that the reconstruction of PIH dowry is similarly robust to phylogenetic tree model and coding of the outgroup. More generally, these reconstructions push the origin of monogamous marriage into prehistory, well beyond the earliest instances documented in the historical record. This implies that the archaeological and genetic evidence for the nuclear family in prehistoric populations may reflect a monogamous marriage strategy; on their own, the archaeological and genetic data can at best provide clues about a monogamous mating pattern. For example, Haak et al. found evidence, through analysis of aDNA samples, of genetic relatedness of one adult male and one adult female with two children recovered in one burial at the site of Eulau, Germany, a late Neolithic community attributed to the Corded Ware culture; they argued that this establishes "the presence of the classic nuclear family in a prehistoric context in Central Europe" . Similarly, Bentley et al. identified a nuclear family, comprising an adult male, an adult female, a mature female, and two children, through analysis of the isotopic signatures of skeletal remains in the communal grave at Talheim, Germany, an early Neolithic community attributed to the Linear Ware culture; previous analysis of the teeth had revealed high similarity between the male and the children, suggestive of genetic relatedness. The Corded Ware and Linear Ware cultures are archaeological horizons of northern and central Europe associated with populations speaking IE languages . The phylogenetic comparative analysis shows that monogamous marriage prevailed among prehistorical IE-speaking societies located in Europe. At least to the extent that evidence from a single grave can substantiate claims such as Haak et al.'s , this suggests that the burial patterns may reflect the monogamous marriage strategy of the Eulau and Talheim communities. Larger-scale analyses of Y-chromosome data provided evidence for a later increase in effective male population size compared to effective female population size, across European and worldwide samples. One possible interpretation of this pattern is that the difference in effective population size was caused by a regime of polygynous mating, which resulted in greater variance in reproductive success for males than for females . Further, Dupanloup et al. interpreted the delayed increase in the effective male population as evidence for a relatively recent shift from polygynous to monogamous mating; based on Pritchard et al.'s estimates for the timing of expansion of Y-chromosome data, they linked this shift to the emergence of food production, between 10,000 and 5000 years ago in Europe and Asia and more recently elsewhere, when "Nuclear families replaced the polygamous, extendedfamily compounds typical of hunting-gathering populations" . Dupanloup et al. use the concept of "nuclear family" as synonymous with non-extended and monogamous family organization, although in anthropology it is used to designate a family unit comprising parents and their dependent children ; technically, therefore, nuclear families exist in societies practicing monogamous and polygamous marriage . The reconstruction of PIE monogamy presented in this paper, with monogamy likely extending back to PIH, falls within the temporal interval identified by Dupanloup et al. , suggesting that monogamous marriage had emerged in Eurasia by that time. However, Dupanloup et al.'s interpretation holds only to the extent that the shift to the "nuclear family" coincided with a shift from polygynous to monogamous mating, with consequent reduction in the variance in male reproductive success. The historical and ethnographic evidence suggest that variance in male reproductive success is comparable in societies practicing monogamous and polygynous marriage . In any case, this pattern is to be viewed against the background of moderately polygynous mating that is believed to have characterized our species' evolutionary past based on morphological and genetic data. Finally, and most importantly, the phylogenetic comparative analysis confutes explanations linking the emergence of monogamous marriage to the development of features of social organization typically associated with the "complex," "modern" societies located in Eurasia. Indeed, investigation of the factors resulting in the shifts from monogamy to polygyny identified by the phylogenetic comparative analysis, and in the corresponding reversals, would be of particular interest. Shifts in marriage strategies may reflect, for example, changes in subsistence systems, as well as historical contingencies such as the diffusion of religious beliefs . Recent theoretical work situates variation in marriage strategies in the context of variation in ecological factors, linking the prevalence of monogamy across Eurasian societies to the development of intensive modes of production . Diamond has convincingly argued that the relative greater "complexity" of these societies, and their consequent "modernization," can also be attributed to ecological determinants that facilitated the emergence of food production in the region. This raises the possibility that ecological factors act as a confounding variable in the observed relationship between marriage strategies and indicators of "societal complexity" and "modernization." An appeal to "complexity" and "modernization" as the terminus of explanation amounts to providing a proximate answer to ultimate questions about the evolution of marriage strategies.

Explanations for the emergence of monogamous marriage have focused on the cross-cultural distribution of marriage strategies, thus failing to account for their history. In this paper I reconstruct the pattern of change in marriage strategies in the history of societies speaking Indo-European languages, using cross-cultural data in the systematic and explicitly historical framework afforded by the phylogenetic comparative approach. The analysis provides evidence in support of Proto-Indo-European monogamy, and that this pattern may have extended back to Proto-Indo-Hittite. These reconstructions push the origin of monogamous marriage into prehistory, well beyond the earliest instances documented in the historical record; this, in turn, challenges notions that the cross-cultural distribution of monogamous marriage reflects features of social organization typically associated with Eurasian societies, and with "societal complexity" and "modernization" more generally. I discuss implications of these findings in the context of the archaeological and genetic evidence on prehistoric social organization.To access this article as a PDF pay-per-view download via BioOne, please click here.

Introduction Endometriosis is a chronic, multisystemic disease of inflammation affecting approximately 10% of the female population . It is defined as the extra-uterine growth of endometrial glands and stroma and may present with a variety of symptoms such as pelvic pain and infertility, resulting in a significant negative impact on individuals' health and quality of life . The most widely regarded theory on the origin of endometriosis dates back to Dr Sampson, who postulated that endometriotic implants resulted from retrograde menstruation back in the 1920s, although reports of aberrant endometrial tissue growth date back to as early as 1860 . --- Historical perspective John A Sampson was interested in exploring the reason for infertility seen in patients with endometriosis, at a time of social concern regarding declining birth rates among upper-class women in the United States . In the context of such societal panic, Dr J Meigs proposed a theory that endometriosis was linked to contraceptive use and delayed childbearing seen most commonly in the 'well-to-do' . This theory gained ground for several decades, substantiated by methodologically flawed research demonstrating increased rates of endometriosis among private White patients compared to the ward Black patient, a dichotomy ridden with confounding and bias . Although some evidence to the contrary started to emerge in the 1950s, it was not until Dr Chatman presented his work in the 1970s that the view of low prevalence of endometriosis in Black patients began to shift . Nevertheless, by this point, a strong bias regarding the impact of race/ethnicity in the epidemiology of endometriosis was perpetuated in the medical community, evidenced by the narrative in medical education literature suggesting a rarity of endometriosis amongst non-white patients, present until the twentieth century . More recent texts continue to suggest lower prevalence of endometriosis diagnosis in Black and potentially higher prevalence among Asians, compared to White women . --- Summary of evidence regarding race/ethnicity and endometriosis Several publications dating back to the 1920s have investigated the epidemiological risk factors for developing endometriosis, including race/ethnicity. This literature was synthesized in a systematic review and meta-analysis by Bougie et al. in order to estimate the risk of endometriosis among various racial/ethnic groups. The review included 18 studies and identified that compared to White women, Black and Hispanic woman were less likely to be diagnosed with endometriosis , while Asian women were more likely to have this diagnosis . Significant heterogeneity was present in the analysis for all racial/ethnic groups, which may have stemmed from clinical variation of included study participants and definition of outcomes, as well as methodological differences in study design. Two studies were not included in the meta-analysis as they reported outcomes of interest in a format not compatible with data synthesis. First, Missmer et al. examined the incidence of surgically diagnosed endometriosis in the Nurse's Health Study II and found that Black women had lower rate of endometriosis diagnosis compared to White women , whereas Asian women had similar rates of disease compared to White women. Hispanic women had lower rates of endometriosis diagnosis compared to White women, although this did not reach statistical significance . These findings should be interpreted cautiously as the studied population was predominantly Caucasian. Secondly, Zhao et al. examined the prevalence of endometriosis-related hospitalization based on the Nationwide Inpatient Sample in 1991 and 1992 in the United States. They observed significantly lower rates of endometriosis diagnosis in Black , Hispanic , and Asian Pacific women compared to White women . A more recent retrospective cohort study using claims electronic health records estimates that 70% of patients diagnosed with endometriosis were White, 6% Hispanic, 9% Asian, and 4.7% non-Hispanic Black . This work highlighted several important themes pertinent to race/ethnicity and endometriosis. First, many of the included studies were of poor methodologic quality and at significant risk of selection bias as well as confounding, particularly from socioeconomic status. Secondly, the majority of patients included in the studies were of White racial origin. Lastly, the majority of studies focused on disease prevalence, without exploring potential variability in presenting symptoms, diagnostic delays, or therapeutic response based on race. Literature looking at uterine fibroids, another gynecologic condition, suggests that there is significant variability amongst different ethnic groups in terms of symptom burden and clinical presentation, not necessarily in alignment with objective measures of disease burden . Flores-Caldera et al. recently presented the results of their international collaborative cross-sectional study 3:2 which established the phenotypic profile of Hispanic/ Latinx patients with endometriosis. Specifically, they identified substantial severity of symptoms, particularly dysmenorrhea and dyspareunia, high pain catastrophizing scores, and overall negative impact on quality of life . Finally, the primary presenting symptom of endometriosis, pelvic pain, may limit clinical consideration of this diagnosis of this condition amongst non-White patients . Historically, medical education has perpetuated stereotypes surrounding Black patients and their experience of pain . Significant racial and ethnic disparities remain across different areas of pain care , with minorities receiving lesser quality pain care than non-Hispanic white patients . These encounters may be rooted in implicit and explicit biases held by healthcare providers including the notion that non-white patients have a higher pain threshold . Similarly, when stereotypes surrounding the prevalence of diagnoses like endometriosis are perpetuated within the broader community, racialized patients may be less likely to seek medical attention for their symptoms. --- Race/ethnicity and endometriosis representation in medical education Endometriosis and race have been discussed in medical education with heavy influence from the gynecology community. The integration of evidence-based medicine has stressed the importance of using high-quality evidence to support clinical practice; however, we must appreciate that there are many long-standing beliefs that are held as 'mantra' in medicine, supported mostly by flawed confirmation bias. The perception of endometriosis as less prevalent in Black patients is widespread amongst foundational textbooks of gynecology, including but not limited to Williams Gynecology, Blueprints Obstetrics & Gynecology, and Speroff's Clinical Gynecologic Endocrinology and Infertility . Textbooks are important to examine as they are widely distributed as educational tools based on expert opinions, and until the recent shift to online resources, formed the foundation of medical education. For example, an excerpt from the sixth edition of Novak's Gynecology, published in 1961 states, 'There seems no doubt that endometriosis is much more common in the white private patient than in the dispensary clientele'. . By the 16th edition published in 2020, the section states that endometriosis 'is found in women from all ethnic and social groups'. . Whereas Novak's revised its content to remove all references pertaining to race and endometriosis, other textbooks removed blatant commentary while still alluding to an ongoing 'controversy' . Other examples of racial bias are more nuanced. For instance, the 2013 edition of Blueprints of Gynecology features a corresponding multiple-choice clinical vignette in which 'Her ethnicity is Caucasian' is correctly identified to increase suspicion for endometriosis . Similar commentary can be found in other gynecology textbooks dating back to the 1960s with the nature and severity of these assertions changing over time. It is of note that many of these comments are made without any appropriate citations. --- The uses and misuses of race/ethnicity in medicine The consideration of race and ethnicity in medicine and biomedical research has been a long-standing, charged, and complex debate. There is an established history of racial injustice in medicine and a hesitance to repeat past mistakes . There are two general positions: either there is strong utility to the inclusion of race in research and medical practice or race has no biological origin and thus should not be included in medicine . To understand each side, it is imperative to define this terminology, which has been used inconsistently. Race and ethnicity are primarily social constructs . They arose through geographical, social, and cultural forces, as opposed to defined biologic constructs. Race is often classified based on continental origin, and historically, genetic variation has been related to geographical mating patterns . Ethnicity is a further construct, related to geography but also considering religion, culture, and language. They are often a result of endogamous mating within continents; thus, they have genetic variation but less than continentally defined groups . Both race and ethnicity can influence socioeconomic status, resulting in unequal access to opportunities and resources and disproportionate morbidity and mortality . Race/ethnicity is often used as a marker for underlying genetics. Epidemiologic and clinical research often divide endometriosis R37 3:2 participants into such categories to investigate hypotheses between environmental and genetic risk factors . Although social determinants of health and access to care must be considered, racial/ethnic differences are often seen despite controlling for such factors. For instance, in a study by Karter et al. , the rate of diabetic complications was evident despite using the same health maintenance organization and after adjustment for various social determinants. Conversely, while these risks are often reported as 'intrinsic differences' between races, they are likely capturing the risk of inequities from exposure to structural racism . Single gene disorders are an example of successful discovery based on race/ethnic considerations. Noting that certain groups display certain diseases, geneticists hunt for a cause, leading to discoveries of the genes for Tay-Sachs, cystic fibrosis, and thalassemia . Mendelian disorders are often traced back to particular groups, such as Ashkenazi Jews, French Canadians, the Amish, or certain European backgrounds , but it should be noted that these groups are not defined by race. Genetic variation is still more commonly observed within continental populations, as opposed to among them . Common chronic diseases, such as cardiovascular disease, diabetes mellitus, and kidney disease, have been seen worldwide, confirming that all populations are susceptible, and variation is more likely due to environment. While race can help target screening for disease-associated mutations, the only way to diagnose a DNA-sequence variant is to test for it . It should also be noted that despite all the literature on the topic, race has not been defined in genetic terms . Further application of race/ethnicity has been in drug responsiveness. It is well known that functional variants of genes encoding drug-metabolizing enzymes exist and understanding a patient's background can allow clinicians to predict drug responsiveness and tailor therapies accordingly . For instance, there has been substantial work in targeting 'race-specific' medical therapy in cardiovascular disease. The Clarification of Oral Anticoagulation through Genetics trial showed a difference between the responsiveness of populations of European and African ancestry with respect to warfarin dosing, necessitating a race-specific approach to treatment . However, researchers must be cautious, as other randomized trials were interpreted to show different responses by race, but further analysis of the results revealed this conclusion was a type I error . These assumptions may lead to clinicians withholding certain medications from certain racial groups, thereby exacerbating the differential care seen between groups. While the above examples describe positive attempts at using race in medicine, there are far more examples of its misuse, of which one of the most interesting areas is in diagnostic algorithms. Used as a concrete proxy for bias, this can be seen throughout all fields of medicine. Vyas et al. explored some of the most common diagnostic algorithms. By including race in these calculations, they suggest that race-based medicine is being propagated, guiding decisions that may further direct resources away from minorities. One of the most widely described algorithms incorporating race is that of estimated glomerular filtration rate . The formula predicts higher eGFR, meaning better kidney function, for Black patients. This is supported by evidence that higher serum creatinine levels are seen in Black people, potentially due to increased muscularity . This assumption may result in delayed referrals, and indeed Black people have higher rates of end-stage renal disease. On the other hand, ignoring race in this algorithm may lead to the prediction of worse kidney function in such patients and result in overtreatment and inappropriate drug dosing . Similarly, the Kidney Donor Risk Index finds that black donor kidneys perform worse, and given that Black patients are more likely to receive organs from Black donors, it is not surprising that they have long wait times for renal transplantation . Algorithmic inclusion of race can be seen across the medical specialties. The vaginal birth after Caesarean risk calculator predicts a lower chance of success if a patient identifies as black or Hispanic, which may deter clinicians from offering a trial of labour . Indeed, non-White Americans have higher rates of Caesarean sections, and it is well known that Black patients have increased rates of maternal mortality . While some algorithm developers do offer sources for these adjustments, these are often found to be outdated and biased. The racial distinctions seen in large datasets are more likely reflecting the toxic effects of racism, such as its physiological consequences, discrimination, and access to care . Borrell et al. cautions that when using standardized algorithms, clinicians should consider whether the inclusion of race would decrease health inequities, leading to better health outcomes. The consideration of race has also led to knowledge gaps in medical research. Years of insufficient funding for research in minority populations have led to questionable generalizability of medical advances to such groups. For instance, less than 2% of National Cancer Institute-funded clinical trials and less than 4.5% of federally funded pulmonary research have included minority populations . The National Institutes of Health requires reporting of all racial or ethnic groups, and despite this, there is a paucity of information and minimal progress in including minority groups in large trials . Endometriosis is another condition affected by the misuse of race. As reviewed above, it has historically been viewed as a condition of White women and a systematic review of the literature identified a strong focus of research on White women, with minimal data on minority groups . While some studies postulate that endometriosis is higher in Asian women and lower in Black women compared to their Caucasian counterparts, other studies comparing women of different races with equal indications and socioeconomic status have failed to note a difference . It is commonly thought that those women of African descent rarely have endometriosis, yet it is one of the most common reasons for African American women in the United States to undergo gynecologic surgery . It has also been shown that in private patients admitted for such surgeries, the prevalence of endometriosis was similar between African American and Caucasian patients . Interestingly, Kyama et al. reported a significantly lower rate of endometriosis in African-Indigenous women compared to African American, indicating that race alone is not an explanation, and more likely due to lack of awareness, lack of access to laparoscopy, limited training on diagnosis and treatment, lack of research interests, and lifestyle factors . In their retrospective study, Shade et al. reviewed charts of African American patients that had undergone surgery for endometriosis and noted that 93% of patients demonstrated uterine endometriotic implants. Although this was a retrospective study without a comparator group, the authors suggest that this finding may indicate a variation in disease presentation compared to other racial/ethnic groups. The debate regarding the use and misuse of race/ ethnicity in medicine is ongoing and fraught with complexities. While race is not a reliable proxy for genetic difference, we must acknowledge that differences do exist between people of different racial categories and this is clinically meaningful . Ultimately, replacing race with genetic ancestry would result in more informative, evidence-based approaches, yet this technology is not yet readily available outside the research environment . While ignoring race may improve equality, it is only through the equity that racial disparities can be tackled . --- Phenomics and endometriosis The advent of genome-wide association studies has gathered a great amount of information suggesting highconfidence genotype-phenotype associations between specific genomic loci and a large number of diseases, including diabetes, obesity, Crohn's disease, and hypertension. Recognizing the importance of considering phenotypic variation among endometriosis patients, Vigano et al. conducted a comprehensive review of the relationship between morphometric traits and endometriosis. They identified some association between BMI and particularly pigmentary trains/presence of nevi and diagnosis of endometriosis. More importantly, they drew attention to the consideration of genomic contribution to the phenotype of endometriosis. Although currently the mechanisms underlying genotype-phenotype relationships remain only partially explained and must be interpreted in the context of multiple limitations, including the inherent variability in quality of published data and the higher order complexity of the genotype-phenotype relationship, it is easily imaginable that a catalogue of nearly all human genomic variations and their relative impact on human diseases will be available within our lifetime . We must appreciate that even with expansion of genomic information that will become available, the majority of phenotypic variation seen amongst endometriosis and other medical conditions will stem from genotype-environment interaction . Genetic variation between populations tends to be geographically structured, as expected from the partial isolation of human populations during much of their history . In this regard, race may be considered first-order approximation to the geographically structured phenotypic variation in the human species . The influence of environmental exposure, resulting from geographic variation, on the development of endometriosis has been suggested . --- Conclusions and future work In summary, we see that there is a strong historical bias regarding the epidemiological impact of race/ethnicity on 3:2 the prevalence of endometriosis. Although the summation of current evidence suggests that endometriosis may be less common amongst Black and Hispanic women, compared to White women, it is imperative to recognize the significant methodological flaws and bias driving the studies performed to date. Furthermore, it is important to question the relevance of this information in the provision of outstanding and individualized patient care. Recognizing the narrative on this topic to date, we suggest the following clinical, education, and research priorities moving forward: . Moreover, it is important to note that race should not be used as a proxy for biological markers or genetic predisposition for a disease . Race also should not be used to simplify systemic contributors when teaching around the underlying cause for disparities in diagnoses . Medical trainees must be taught social determinants of health in order to holistically serve diverse patient populations. 3. Further investigation into the epidemiologic risk factors predisposing the development of endometriosis should be encouraged in order to identify at-risk individuals and implement early detection and appropriate treatment of the condition. Research exploring the unique presentation and treatment of endometriosis amongst patients may explore race and ethnicity but needs to include these factors in a sensitive manner, reflecting on underlying social constructs. Any researcher including race/ethnicity when studying endometriosis should reflect a priori on the reason and implications of including this factor in their study. We advocate for the adaptation of an individualized and patient-centred approach to the management of endometriosis to achieve more equitable and improved care provision for all endometriosis patients. --- Declaration of interest O Bougie has participated in a speakers' bureau and received research grants and consulting fees from Bayer Pharma, Allergan, Hologic and AbbVie. The authors confirm these sponsorships had no involvement in the study. I N and C W have no disclosures. --- Author contribution statement All authors contributed to the research and manuscript preparation. They all approved the final submitted version.

Endometriosis is a chronic, multisystemic disease often presenting with significant phenotypic variation amongst patients. The impact of race/ethnicity on the prevalence of endometriosis, as well as disease presentation, is a question of interest which has been explored for the last century. This narrative review explores the historical perspective of endometriosis and race/ethnicity as well as the evidence available to date. Furthermore, we discuss the potential implication of the bias perpetuated on this topic, specifically in the areas of medical education, research, and clinical care. In consideration of these intersecting realms, we suggest priorities for future consideration of race/ethnicity as it pertains to the delivery of care for endometriosis patients.

Introduction Family is a very important social institution of the society. It is one of the basic institutions of the society which breeds actors of other social institutions. No one exists without some form of family. It is only in literature that societies are portrayed without families. An individual's life revolves around the family at one period or the other during his lifetime. The word 'Family' was derived from the Latin word famulus which connotes servant. Inference taken from this is that family comprises of people who are meant to serve one another. And in a typical African family which consists of a man, woman with their children , people are interdependent on one another. Every human society has adopted the family system. It is the lowest unit of social organization. This has attracted several disciplines such as Anthropology, Archeology, History, Medicine, Law, Psycho logy, Sociology and Social studies among others to give special attention to the study of the institution which Erinosho described as the bedrock of value. The institution of the family formed the basis of social relations and was essential to the survival of the individual in the African traditional societies. But it is important to note that as industrialization set in and new institutions came to limelight, family roles and relevance were taken up by these emerging institutions. Although family still remains the basic unit of social organizations but the complexities of societies and the current era of globalization has ushered in several changes and altered the originality of the family structure. --- Family Defined Family is a universal institution and as a result, it will be very difficult to give a universally acceptable and applicable definition in the face of diversities in structure and varying cultural practices of societies. As such, within the context of this chapter, family will be defined based on its applicability to African society and easy understanding of students. Family can be defined as a group of people related by blood or marriage, who live together, co-operate economically and care for their young ones . According to Giddens , a family is a group of people who are intimately related by kinship and whose adult members are responsible for caring for children. A family may also be defined as a small collection of individuals who have face-to-face interactions and are linked through kinship or marriage. The concept of family exists in society. It may also be thought of as a social structure that has impact over society. A civilization cannot exist without family. Murdock defines family as a social group defined by shared housing, financial integration, and procreation. Implicit from these definitions given is that the concept of family has something to do blood relation, marriage, and household. Overtime with the presence of the threat of divorce, single parents, unmarried cohabitation and gay marriages, several definitions of family have lost their originality and are being threatened by the changing trends. Functions of family in the society 1. Socialization: Every individual's initial point of interaction in society is with his or her family. Socialization is the process through which a person becomes an accepted member of society. It is frequently stated that "home" is the first school, and the mother is the first instructor. An infant learns conventions such as hygiene, eating habits, and so on from his family members. The family, via its parents, guardians, and older relatives, assists children in becoming well-integrated and productive members of society. From childhood, the children are indoctrinated with societal standards and values in order for the child to fit into anticipated roles and behaviors in society. --- Regulation of sexual behaviour: Each society controls sexual behavior in order to preserve familial organization and personal liberty . Family systems define standards that govern sexual behavior. These norms may forbid premarital sex or describe the qualities of suitable sexual marital partners. Laws forbidding marriage and sexual interactions between relatives are examples of such standards. --- Reproduction function: For there to be continuity, members of society who die must be replaced. Family offers a culturally and legally authorized setting for new members to be born and raised in . 4. Provision of emotional support: one of the functions of the family is taking care of the emotional and physical needs of its members. Irrespective of how old a member of a household is, such a member still craves for meaningful social ties to others. The human life cycle is such that there is always a stage to be extremely dependent on others . In Africa, people are not only dependent on one another but very interdependent and as such come to one another's aid when assistance is required. 5. Social security: Family provides a sense of security to its members. An individual feels secured when he is with his family members. In many societies especially in the rural communities, any attack upon a person is considered an attack on the entire family and as such all family members stand to defend the person. Although most families are now nuclear in structure but the ties with other members of the family who are heterogeneously scattered in different communities are still maintained especially in Nigeria. 6. Ascription of status: Since individuals cannot choose their parents before birth, the family into which a child is born confers a genetic and social status. On the genetic or biological status, a child whose father is a king automatically qualifies to be in the lineage of royalty and as such can become a king also for the achieved status, a child who is born into a wealthy family also enjoy the wealthy status of the parents which can serve as a determinant of the child's aid to attain wealth without having to engage in much hard work. 7. Religious function: Most times, the religious practice of the family into who one is born is always the religious group one belongs until maturity or marriage sets in. Since the infancy will be socialized by the family into which he/she is born, the family has a strong influence in determining the religious practice of an individual. 8. Economic function: Since the family is the interphase between an individual and the society, the economic aspect of the family is also catered for from infancy. Family in the traditional societies engaged in joint effort of working and sharing i.e. every member of the household was an economic asset because the needs and aspirations of every member was jointly provided. Although the situation has changed and a large number of families now are not engaged in agriculture-based occupation that requires the services of every member but even with white collar jobs, several families that reside in the urban jointly cater for the family needs. --- Marriage Marriage is an institution that results into family. Marriage is a societal institution that allows individuals to form family system with one another. Marriage can take one of three forms: monogamy, polygamy , or group marriage. --- Marriage practices Endogamy: This is a practice which requires that mates be selected within certain groups. The groups are commonly socio-economic, socio-religious and ethnic based. According to Oyeneye the practice is prevalent all over the world but some cultures emphasize it more than others. In India, the Indian caste system is an example and in Nigeria, the Osu caste system also exists in the eastern Nigeria. There are some other instances such as the case of some marriages contracted within relatives among royal families in Northern Nigeria in order for the royal blood not to be contaminated by marrying from outside the clan. Exogamy: In this practice, there is prohibition against the selection of a spouse within certain groups. When close relations have sexual intercourse with one another it is regarded as incest taboo. This incest taboo prohibits individuals from selecting spouses amongst members of the family and close blood relations. According to and Shankar Rao, , the rule of exogamy is that individual should look for spouse from another family, clan, tribe or village. Oyeneye identified different types of marriage being practiced in Africa. These include: --- Types of Contemporary marriage Marriage by mutual consent: This is an association between man and a woman living together as husband and wife without a formal bond such as approved by any religious institution or family members. And because such association exists without the acknowledgement of parents, this marriage is usually not stable . Any of the couple may decide to break the relationship. This practice is common among some career conscious individuals in the urban areas such as Lagos, Port Harcourt, and Abuja among others in Nigeria. Trial marriage: This is a contracted kind of marriage which is bound to expire at the sight of growing incompatibility. It is somewhat similar to marriage by mutual consent but trial marriage is common among students of tertiary institutions and middle class clerical workers in Nigeria. Although this type of marriage is not yet approved in Nigeria but it has become a common practice among people to start living together and use the opportunity to closely observe each other if their character can match one another for the relationship to be further cemented. People who engage in this practice are referred to as live-in-lovers. Marriage by ordinance: This is a marriage contracted in a court of law before a court registrar, magistrate or any designated government official who has authority to contract marriages. At the end of the marriage, certificate is usually issued to the couple but with emphasis that it should be handled by the wife. Marriage under the ordinance cannot be dissolved until after five years of its contraction and such dissolution can only take place in a court of law. Marriage by ordinance only permits both couple to have a spouse at a time and because of this clause; a lot of couples have dodged contracting their marriages in a court of law. Some men for the tendency of infidelity, few ones for the fear of infertility or inability to produce a male child usually reject this type of marriage. Christian/Muslim marriage: In a religious solemnization, the families of the bride and groom are represented or present to serve as witness and show approval for the consummation of two consenting adults. Most Christian marriages take place in the church and it is usually referred to as white wedding while the Muslim marriage usually referred to as Nikhai is mostly done outside the mosque. Both Christian and Muslim marriages are mostly combined with the ordinance and as such, the dissolution requires that both parties be present or represented in a court of law. Customary marriage: This is a traditional marriage system which permits the groom to perform all necessary rites and dues before being betrothed to his wife. Under this practice, the families of both bride and groom must come into agreement to allow their children marry one another. History of sicknesses and diseases, moral and social qualities of either family as well as the hard working nature of the groom are factors always considered before the marriage is consummated. Among the Yorubas, there is usually provision for an intermediary who sees it all from both families point of view and report any anomaly or foul play noticed in the course of his visitations. If nothing is detected in the course of his findings then both families can be united in the bond of marriage. Among the Yorubas, once two families are married it is believed that they have become one single family and hence no two members of either family can have any strange feelings of love for themselves, it is a forbidden act. In the Fulani tradition, there is a marriage custom called the Sharo . The purpose is to prove a young man's courage and ability to endure the rigors of a married life. If the young man cannot endure the pain of flogging then he is not ready to marry. Today, this system is going fast into extinction. Escape marriage: This type of marriage happens when a woman leaves her husband to marry another man, without any formal divorce or payment of compensation to the former husband Onwuejeogwu . The new husband takes the wife to his house, slaughters a cow which symbolizes the validity of the marriage. If a woman involved in escape marriage gets tired of her new husband, she may decide to return to her former husband or be married to another husband. In this type of marriage, there is no limit to the number of husbands a woman may take. This type of marriage is common among the Fulani tribe of Nigeria. Child marriage: It is referred to as the Koggal-Pibol, it is also common among the Fulani tribe of Nigeria. Under this arrangement, a girl is betrothed to a boy when they are both still very young or to a much older man. In some Fulani resident communities, the girls father gives her to the father of the boy who in turn takes care of her till she is old enough for marriage. This practice is valued because it enhances group integration. Although this has been negatively interpreted as a lot of families who are into this practice are reported to have jettisoned the place of keeping the young girl for a young boy or at least permitting her to attain maturity before sexual intercourse is introduced. Infact, a lot of old and wealthy men have resulted into capitalizing on this practice to find virgins for themselves in the young girls whom the culture described that they should be nurtured till the level of maturity and the problem associated with the recent arrangement is that should the husband of this young wife die, life may become miserable for the woman as there may be no one to cater for her and the kids. Woman marriage: In this case, a woman marries another woman, pays her bride price and acquires the rights of a husband with respect to wife. After the marriage, the woman who paid the bride price can betroth the new wife to her husband, brother, son or close relations. Although, the most popular of all this practice is the one that sees the woman marrying on behalf of her husband to neutralize the effects of the harsh ethnic system which prevents women who have no male children from inheriting part of their deceased husband's property and being part of his agnatic lineage. This practice is peculiar to the Igbos in Nigeria. Marriage by inheritance: This is common in traditional African societies where when a man dies, his wife can be inherited by his kinsmen most especially the siblings of the deceased. This is mainly to cater for the woman and raise children in the name of the deceased. Also, because marriages in the traditional African societies were usually conducted between families, most families see it as a loss when a man dies and his wife is allowed to married outside the family. Hence, one of the kinsmen is chosen to marry the widow in order to cater for her and probably the children of the deceased most especially when the woman is still very young. Surrogate: This involves one woman carrying a foetus produced from the egg of another woman. Haralambos, Holborn, Chapman and Moore stated that surrogate is more of a mutual agreement between a woman and a couple or a single parent. The surrogate mother is usually contracted to carry the baby from foetus stage to the level of delivery and once the child is delivered, it is delivered to the contracted party which may be couple, single parent or willing parties. Smart also noted that this practice is becoming a common phenomenon among same sex partners such as gays and lesbians who also crave to have children in their union without adoption. Merriam-Webster Dictionary described that this can be referred to as levirate --- Family and Social Change A lot of changes are taking place in the institution of family which quite often poses a threat to the very survival of family system universally. Giddens , Henslin , Ferrante and Haralambos, Holboln, Chapman and Moore stated that the following trends have been observed in the institution of family: 1. Unwed mothers: It is gradually becoming a universal culture for some women to voluntarily choose not to marry but have children. Although some are victims of circumstances such as rape, rejected pregnancy, teenage pregnancy, and children accidentally born out of prostitution. These set of women chose not to marry for several reasons. Some out of the fear of being maltreated, past sexual abuse experiences, fear of unknown, and quest for fame. --- Live in relationship between couple without the ceremony of marriage: This is often referred to as living lovers or trial marriage. This is common among young adults who want to observe one another for a period of time before deciding on marriage. It is often practised by students of tertiary institutions. Although this practice has been on for long because a lot of people who live together as couple and give birth to children without the ceremony of marriage also fall under this category. This practice is not only restricted to the youth but also some elderly persons in the society who find the ceremony of marriage very rigorous to undertake. A lot of people run from being implicated legally in case they engage in infidelity. --- Extra marital affairs: This is almost a universal practice. In Nigeria when a woman engages in this act she is often condemned instantly but the case is not so for the male counterpart who sometimes boast publicly of his potency. Although, the legal marriage system negates this attitude but infidelity is almost normalized in most African countries except for the developed countries that take legal actions against persons who are found guilty in this phenomenon. 4. Increased rate of divorce: This practice is said to be a product of industrialization and the quest for gender equality. Although most African families curb growing intolerance which may lead to divorce, it is important to note that some educated young wives are beginning to develop a new profit making venture in their claim for divorce. In most divorce cases reported, infidelity, growing incompatibility and wife battering among others are factors responsible. Calhoun, Light and Keller stated that the likelihood of divorce is highest when: a. The couple lives in a city. b. They both work, but their earnings are low. c. They got married young. c. They haven't been married for a long time. c. The wife has egalitarian beliefs on household labor division, but the husband does not. f. Neither the husband nor the wife possesses religious beliefs. g. Both the husband and the wife have liberal attitudes. h. Both husband and wife have a negative outlook on life. i. Either one or both parents are divorced or single parents. --- Boarding school for children: Boarding school education for children from a very young age which makes them lose their attachment with the family. Moreso, a lot of caregivers have risen to the occasion. People now take it as a job to raise other peoples childrenat the absence of the mother. 6. Decision not to procreate: This tendency is particularly observed among the highly educated couples who feel that they have no time to bring up children or can adopt because of the rigors of child bearing and child rearing. This is also common among artists and people who are too dedicated to their profession. 7. Decision of youngsters to remain unmarried on account of high degree of dedication to profession. 8. Increasing rate of domestic violence: such as child abuse, wife abuse and abuse of the elderly. 9. Increase in employment opportunities for women: Presently there is a universal agitation for the incorporation of women in organizations because of the perceived level of social inequality, more women now have jobs unlike before and as a result of their new status, they have lesser time for the family. 10. Decline of the breadwinner system: Since the society is encouraging that both spouses work to sustain the family in the face of industrial reality, there is decrease in continual dependence on the man as the sole bread winner of the family. Rather, there exists joint effort on the part of the couple to cater for the needs of the family. St. Abraham noted that the breadwinner system is mostly common in the traditional African societies and in an urban area it will not thrive. 11. Increased Life Expectancy: More members of the family are now conscious of the health status of pregnant women, nursing mothers and infants as well as the physically challenged individuals. This has helped to save a lot of lives in the family. This is partly due to the increasing efforts of the government to improve the lives of every individual. 12. Decline of arranged marriages: A lot of marriages conducted now are based on mutual consent between the couple rather than imposition by the family. More people first meet themselves, fall in love and then agree to marry one another. The involvement of family in marriage is no longer in the area of finding suitable partner for their wards but to only perform ceremonial functions 13. Decline in parental authority: Due to the growing rate of civilization and the increasing number of graduates and elites, more youth crave to be personally independent and find their source of survival away from their families. Their quest for survival has separated them from authority and control of the elderly members of the family. And in some cases where the parents have little or no time for their wards who have been conscripted to the boarding schools, these wards come back into the family with a separate culture of their own part of which is self dependence and decline in parental control because they have not been consistently in contact with their parents to understand their dos and donts. 14. Teenage pregnancy and parenthood: More teenagers are being put in the family way in recent times. Some through abuse and others via ignorance or exuberance. Though teenage marriage is a permissive practice in some part of Northern Nigeria. It must also be emphasized that because most of these teenagers did not prepare for induction into motherhood, a lot of them struggle to cater for the children born especially if the child is born out of wedlock. Also, most teenage mothers have some health challenges which might have emanated in the course of the child bearing and such complications threaten either or both the lives of the mother and child. --- Structure of the Contemporary family According to Giddens , families in the world are in transition. Several pluralities have been witnessed and other structures of the society have overtaken the responsibilities of the family. For the procreation function of the society, the health institution has engineered the establishment of breeding and cloning of the human species. Animals and laboratory-made materials can incubate premature babies ejected at early stage from their mother. Sexual gratification is also gotten from commercial sex workers and people nowadays derive pleasure from well defined contractual marital arrangements with expiration periods as well as with multiple sexual partners even though these are not legitimate. On the socialization function of the family, schools and religious organizations have replaced the family. Children spend much time with their counterparts and teachers in school than with their parents. And as a result of the busy schedules of parents mostly in the urban areas, the level of attention mothers give to their children is on the decrease coupled with single parenting, and the death of one or both parents. In this vein, several educational instructions and religious organizations have taken up the task of instilling the norms and values of the society in the children since complexities is beginning to set in into the family. The level of closeness of members of the family is also being threatened by industrialization and urbanization. The level of ascribed status has reduced because of the economic conditions of most developing society. Hence, a lot of children fend for themselves and learn from their peers instead of being initiated into the societal norms by their family members. This partly explains why a lot of social problems have increasingly become part and parcel of so many societies in the world. --- Conclusion The primary school of citizenship is the family. Every person is born into a family, grows up in it, works for it, and dies in it. The individual becomes emotionally attached to it. The first lesson in social responsibility and acceptance of self-discipline is imparted to the kid through parental care. The family is the foundation of societal organization. It holds a nuclear power status in society. However, despite the relevance of the family in the society, if proper care of the young ones is not taken as priority, the family can become an active institution which breeds delinquents and destitute as a lot of functions are neglected by the modern day family and the efforts of other institutions at managing the lapses of the family has not been a perfect job done. Hence, there is need for every family to hold with uttermost importance the place or morals, socialization and regulation of individual member of the family's behaviour.

Given that social institutions are the basis of any society, they must ideally operate in unison with functional necessities for any society to function and then flourish. The plethora of issues confronting Nigeria as a country may be traced back to weak, incompetent, and dysfunctional social institutions that have failed to alter the status quo. According to Talcott Parsons, society is analogous to the human body, and in order for the body to thrive, all of its elements must collaborate. For Nigeria to advance, all social institutions, including family, school, religion, politics, and the economy, must work together to create repeatable results. It is against this background that this paper sought to examine the role of family structure in Nigeria and their pro-activeness in propelling national development. Literature was extensively reviewed from relevant publications and journals and it revealed that the family structure in Nigeria is gradually becoming weak and dysfunctional. This is attributed to a lot of changes that are taking place in the institution of family which quite often poses a threat to the very survival of family system universally. It was then concluded that there is need for every family to hold with uttermost importance the place or morals, socialization and regulation of individual member of the family's behaviour.

HOW ARE OLDER PEOPLE FARING POST-PANDEMIC? EVIDENCE FROM THE ENGLISH LONGITUDINAL STUDY OF AGING Chair: Giorgio Di Gessa Co-Chair: Paola Zaninotto Discussant: Paola Zaninotto This session provides insights into the experiences of older people in England post-COVID-19 pandemic. Evidence suggests that stay-at-home and lockdown measures during the pandemic impacted several aspects of people's lives with detrimental consequences for their wellbeing and mental health, particularly among older people. Little is known, however, on whether and to what extent there has been a return to 'normal life' since COVID-19 restrictions were lifted. Using data from the English Longitudinal Study of Ageing this symposium aims to provide new evidence on the experiences of older English people since the successful and rapid COVID-19 vaccination rollout and the easing of restrictions in England through the second half of 2021. ELSA is an ongoing longitudinal biennial survey representative of individuals aged 50 and over in private households that has collected data before the pandemic , during the pandemic , and post-COVID-19 pandemic . Exploiting the richness of this dataset, this symposium will present the most up-to-date picture of how older people are faring post-pandemic. Results will focus on mental health and wellbeing, social isolation and loneliness, employment and financial status, as well as social participation . Abstract citation ID: igad104.1376 --- SOCIAL ENGAGEMENT AMONG OLDER PEOPLE IN ENGLAND SINCE THE COVID-19 PANDEMIC. Giorgio Di Gessa, University College London, London, England, United Kingdom Volunteering, providing grandparental childcare, and provision of family care were quite common activities prepandemic among older people. However, during the pandemic, older people in particular were strongly advised to stay indoors, to work from home, and to avoid or at least limit interactions with people outside of their immediate household, including grandchildren and friends. As a result, evidence from the English Longitudinal Study of Ageing showed dramatic changes in the level of engagement in these socially productive activities. About 10% of grandparents stopped looking after grandchildren altogether during the first 9 months of the pandemic, with 22% reporting an overall decrease in the amount of grandchild care provided. Similarly, among those who were volunteering or caring for someone outside their household pre-COVID-19, almost two thirds decreased or stopped altogether engaging in these activities, with overall negative consequences for their mental health and wellbeing. To date, though, little is known on whether, in emerging from the current pandemic

questions were included to explore caregivers' feelings of preparedness and family support. Of all participants, 206 family caregivers responded to the open-ended questions. Nearly 40% (n=79) of these caregivers were providing care to a family member with Alzheimer's disease or related dementia. Qualitative methods were used to analyze data, develop a coding scheme, and identify themes. Findings suggest that most family caregivers are providing care without adequate help, support, or communication from other family members. This lack of support seems to leave dementia caregivers feeling less prepared and more frustrated than other caregivers. Our findings highlight the importance of family communication about advance care planning and caregiving responsibilities to promote family caregiver preparedness and well-being, and effective care and quality of life for an individual at the end of their life.

Introduction Physical inactivity can be a fundamental cause of various public health problems, especially chronic diseases. In countries with fast-growing economies, the decline in physical activity is even more pronounced. For example, the level of physical activity of 1.3 billion people in mainland China is experiencing a steeper decline than in any other country: the level of physical activity has dropped by 45% in less than a generation [1]. Numerous studies have shown that regular physical activity can effectively reduce the risk of preventable chronic diseases [2][3][4][5]. Environmental improvements can provide health benefits by promoting physical activity. However, the urban form and social environment of Chinese cities are significantly different from that of many Western cities. It is not clear whether the associations between environmental characteristics and physical activity from Western cities can be directly applied to China [6]. For example, previous studies on transport-related physical activity in China have shown little association with built environment [7], because the most common form of it is the daily commute to workplace [8]. Besides, density might also impede walking and other outdoor sports activities [9,10], which is not in line with the existing literature. Extremely high density limits open spaces and parks, which could lead to serious traffic barriers, safety, and pollution problems [6,11]. However, evidence of non-major Chinese cities, with lower density than first tier cities, is lacking. Therefore, this study provides some insights into the interaction among various factors associated with physical activity and health outcomes in Chinese non-first-tier cities. Evidence has reported the association between built environment and physical activity, with land use mix, density, and connectivity as pivotal determinants of physical activity [12,13]. Other walkability related factors, such as parks and squares, and pedestrian infrastructure also affect physical activity [14]. Besides, easy access to parks and other recreation facilities has been associated with more leisure-time physical activity [15]. Adults tend to be more physically active when they live in higher density, mixed-use neighborhoods with destinations such as shops and parks within walking distance. However, findings have been inconsistent, perhaps owing to multiple modes of assessment and overreliance on self-reported measures [13]. On the other hand, objective environment attributes tend to affect physical activity through people's perception of the environment according to ecological models of health behavior. The results of objectively-assessed and perceptions of the same built environment do not have high consistency in physical activity [16], as perception may be influenced by personal cognitive and emotional factors [17]. Only 8.2% of the environmental factors are related to the same result. The influence of perceived environment on physical activity is slightly higher than that of the conceptually comparable objectively-assessed environment [18]. However, few studies have demonstrated the mediation and moderation effect of neighborhood environment and physical activity relations. Research has documented that the association between the number of parks and moderate and vigorous physical activity was mediated by its perceived indicator [19], facility count and population density were associated with neighborhood walking and physical activity via the perceived neighborhood environment [20]. While, the association between built environment and physical activity varies according to the individual socioeconomic backgrounds, such as gender, age, and education, but there is no consistency [21][22][23]. Higher socioeconomic status may lead to higher physical activity [24]. In addition, the associations of objective intersection density and land use mix with moderate and vigorous physical activity are moderated by both gender and perceived pedestrian infrastructure/safety [19]. Plus, education and gender moderate the association between safety from crime and meeting high physical activity levels [21]. Clear relationships between perceived neighborhood features and built environment with physical activity levels remain elusive [19,25] In addition to built environment, individual and social environment have multilevel interactions with physical activity according to the ecological model [26]. Social determinants of health also have robust associations with health status, including a wide range of elements, such as socioeconomic status, social networks, social support, social cohesion, social capital, and so on [27]. Social capital is the most used which contributes to various health outcomes [28] and physical activity [29,30]. Previous studies examining the association of social environment on health outcomes emphasize different aspects of the social environment [31,32]. The social factors that can affect health are the degree, intensity, and quality of our social connection with others [33]. This paper focused on the connections between residents and neighbors. However, too little work has been devoted to the effect of social environment as a moderator between built environment and physical activity, especially in China. The interaction among various factors is still the least understood [21]. Given these considerations, this paper aims to explore whether objective measures of neighborhood built environment are directly associated with, indirectly associated with physical activity and health outcomes via the perceived environment, and whether perceived environment is directly associated with physical activity and health outcomes, all controlling for demographic characteristics and taking social environment as the moderator. We conduct a series of mediation models to test the cross-level relationships between the different aspects of built environment and physical activity. The results provide an evidence base for community development in Dalian, China. --- Materials and Methods --- Study Design and Participants We conducted the survey in Dalian, situated in the Northeast coastal area of China . Due to the hilly terrain, more than half of the residential communities have different forms of the slope , which may lead to obstacles in driving and walking. In particular, the average topographic elevation range in the study sample reached 40 m. The study sample was drawn from the four urban districts, including Zhongshan, Xigang, Shahekou, and Ganjingzi districts, which had approximately 2 million people and covered an area of 600 km 2 . The "neighborhood" is defined as an area within a 10-15 min walk from home. The study sample was restricted to individuals aged 22-64 that had lived in the neighborhood for at least one year. University students aged 18-22 were not eligible for this study because they tend to live on campus or study in other cities [8]. Participants also excluded the special age group, like people over 65, owing to the different recommended amounts of physical activity to stay healthy [34]. --- Materials and Methods --- Study Design and Participants We conducted the survey in Dalian, situated in the Northeast coastal area of China . Due to the hilly terrain, more than half of the residential communities have different forms of the slope , which may lead to obstacles in driving and walking. In particular, the average topographic elevation range in the study sample reached 40 m. The study sample was drawn from the four urban districts, including Zhongshan, Xigang, Shahekou, and Ganjingzi districts, which had approximately 2 million people and covered an area of 600 km 2 . The "neighborhood" is defined as an area within a 10-15 min walk from home. The study sample was restricted to individuals aged 22-64 that had lived in the neighborhood for at least one year. University students aged 18-22 were not eligible for this study because they tend to live on campus or study in other cities [8]. Participants also excluded the special age group, like people over 65, owing to the different recommended amounts of physical activity to stay healthy [34]. We developed an online survey that was completed by participants over a two-month time frame between July and August 2018. The survey was advertised through Weibo and Wechat public accounts. The online survey instrument consisted of four sections: general socio-demographic characteristics, individuals' perceptions of their neighborhoods, participation in physical activities, and health outcomes. In total, 890 survey respondents started the online survey. Data cleaning was the key step to ensure the data quality of this paper, including the elimination of missing values, outliers, and error values. Only 649 target samples had a particular time of physical activity and eligible dwelling address . We developed an online survey that was completed by participants over a two-month time frame between July and August 2018. The survey was advertised through Weibo and Wechat public accounts. The online survey instrument consisted of four sections: general socio-demographic characteristics, individuals' perceptions of their neighborhoods, participation in physical activities, and health outcomes. In total, 890 survey respondents started the online survey. Data cleaning was the key step to ensure the data quality of this paper, including the elimination of missing values, outliers, and error values. Only 649 target samples had a particular time of physical activity and eligible dwelling address . --- Measures --- Outcome Assessment The dependent variables included frequency and duration of moderate and vigorous physical activity, frequency and duration of walking, and health outcomes. The modified version of the International Physical Activity Questionnaire short version was used to measure total walking and physical activity during the past 7 days. Participants were first asked whether they had participated in at least 10 min of walking, moderate physical activity , or vigorous physical activity over the past 7 days. Those who said yes to any of them continued with the questions. Questions included how many days they walk or do moderate/vigorous physical activities, and how much time they usually spent on one of those days doing activities. Response options ranged from 0 to ≥60 min/week. Further, we multiplied activity frequency values by the midpoint of the range of hours reported for a given activity to calculate total physical activity time . Health outcomes contained both physical and mental aspects . Body mass index was calculated as weight divided by the square of height . Sense of community can be an indicator of social capital [35]. Sense of community had a decisive influence on mental health [36] and was also associated with walking [37]. In this paper, sense of community was the product of a four-item Likert scale combining two items into one scale, including "Living in my neighborhood gives me a sense of community", and "I would be willing to work together with others on something to improve the living environment in my neighborhood". Additionally, participants' previous chronic disease were included in the questionnaire. --- Socio-Demographic Characteristics Socio-demographic covariates were age ; gender ; educational attainment ; economic-level ; and car ownership . All socio-demographic characteristics were also considered as potential moderators. We --- Measures --- Outcome Assessment The dependent variables included frequency and duration of moderate and vigorous physical activity, frequency and duration of walking, and health outcomes. The modified version of the International Physical Activity Questionnaire short version was used to measure total walking and physical activity during the past 7 days. Participants were first asked whether they had participated in at least 10 min of walking, moderate physical activity , or vigorous physical activity over the past 7 days. Those who said yes to any of them continued with the questions. Questions included how many days they walk or do moderate/vigorous physical activities, and how much time they usually spent on one of those days doing activities. Response options ranged from 0 to ≥60 min/week. Further, we multiplied activity frequency values by the midpoint of the range of hours reported for a given activity to calculate total physical activity time . Health outcomes contained both physical and mental aspects . Body mass index was calculated as weight divided by the square of height . Sense of community can be an indicator of social capital [35]. Sense of community had a decisive influence on mental health [36] and was also associated with walking [37]. In this paper, sense of community was the product of a four-item Likert scale combining two items into one scale, including "Living in my neighborhood gives me a sense of community", and "I would be willing to work together with others on something to improve the living environment in my neighborhood". Additionally, participants' previous chronic disease were included in the questionnaire. --- Socio-Demographic Characteristics Socio-demographic covariates were age ; gender ; educational attainment ; economic-level ; and car ownership . All socio-demographic characteristics were also considered as potential moderators. We controlled for demographic covariates that may confound associations between neighborhood environment, physical activity, and health outcomes. --- Perceived Neighborhood Environment The abbreviated Chinese version of the Neighborhood Environmental Walkability Survey was used to assess an individual's perceptions of his/her neighborhood that was determined to be valid and reliable in a Chinese population [38]. After translation, NEWS-A and the IPAQ were tested for their reliability and validity. Participants were asked to evaluate their neighborhood by responding to statements concerning various environmental attributes. The response format was a four-point scale ranging from "strongly disagree" to "strongly agree" . Negative items were reverse-coded to match the remaining items, which included the following: traffic nearby streets, steep streets, major barriers, separated sidewalks by parked cars or grass/dirt strip. In this study, not all parts of the NEWS-A questionnaire items were selected. Particularly, items included those were conceptually comparable to the objective indicators and other aspects . Social environment factors were also added to the questionnaire, including social interaction and social activities . --- Objective Built Environment We measured 10 built environments, including land use mix, density , connectivity , accessibility , slope, construction quality , using geographic information systems software. The land-use mix was represented by the "Frequency Density" of each land use unit. Land use mix is the most commonly used index. Land use mix degree can be calculated in three ways; accessibility, intensity, and form [39]. Frequency Density represented the quantity or density of specific destinations and the proportion of different land use within the study area. The land use form identification was conducted through BAIDU POI , data describing facility locations. The POI data was divided into six types; residential , commercial and business facilities , green space and plaza , industrial , administration and public service , street and transportation , depending on Chinese land use classification [40]. For each functional unit, the index Frequency Density and Category Ratio was constructed to identify functional properties. The calculation formula was as Equations and : F i = n i N i , C i = F i 6 i=1 F i × 100%, i = 1, 2, . . . , 6, where I stands for POI type; n i indicates the number of POI of type i in the unit; N i means the total number of POI of type i; F i denotes the frequency density of POI of type i in the total number of POI of this type; C i refers to the proportion of the frequency density of type i in all types of POI in the unit. Street connectivity was measured as the number of street intersections and road network density and the number of intersections, based on road network data from ESRI Street Map. Intersection count was defined as the number of three-way or greater intersections within the buffer. Facility count was derived from the Baidu POI, which included data related to physical activity . We assumed that these resources would be correlated with physical activity. Especially, we used the standard deviation of the elevation within the buffer area to represent the variations of the slope, with the data derived from Google Map. Additionally, the average housing price and construction year were used to reflect the general construction quality of the residential unit, derived from Lianjia . We created a 400-m radius buffer around each geocoded home address. Generally, most people prefer to walk within 400 m . Therefore, 400 m has been used as the value of acceptable walking distance, and features of buffers larger than 400 m have also been linked to walking [41]. An individual will walk up to 1600 m to reach a destination, but the most proper spatial context is unclear for understanding the relationship between the built environment and health [42]. Particularly, under 400 m scale, there were more built environment elements associated with the perceived environment and health results, compared with other scales in author's other research. Accordingly, we used 400 m as a radius to establish the buffer zone in this paper. Data were analyzed using ArcGIS 10.5 , and PROCESS© v3.1 for SPSS®v24.0. --- Statistical Analysis --- Data We adjusted the NEWS-A scale to better reliability and validity. First, Bartlett's test of sphericity and Kaiser-Meyer-Olkin factor analysis were performed on the data, with the results fitting for factor analysis . Then, we used the Principal Component Analysis method to test validity. Accordingly, we eliminated the items which by themselves created a component and did not load on the un-rotated or initial component. The deleted item was dead-end streets. After adjustment, the overall reliability of the questionnaire items showed a value of 0.806, and five common factors were identified. However, the five components' dimension was not completely consistent with the original dimension in NEWS-A scale . Next, we made the related items in each component into one scale using the scoring system for NEWS-A. Ultimately, perceived neighborhood attributes included accessibility and street connectivity , walking obstacles , pedestrian environment, aesthetics, and safety. We also calculated Z-scores of all independent variables for data standardization to be used in regression models. Besides, logarithmic transformation of dependent variables were carried out due to its skewed distribution. --- Analysis The data analysis procedures were divided into three steps. First, one-way ANOVA was used to differentiate the health outcomes and perceived neighborhood environment among different social parties. Second, multiple logistic regression was used to examine the effects of different physical activity behaviors and health indicators on self-reported health outcomes. Third, we used a four-step mediation regression to analyze the effects of the built environment on physical activity and health outcomes. This paper tested mediation with regression analysis in four steps. We first and ) tested the correlations between objectively-assessed environment variables and physical activities , as well as taking the corresponding perceived environment attributes as the mediator variable . This process can compare the relationship between the objective and perceived environment and examine the mediation effect . We then ) examined mediation effects controlling for socio-demographic variables in step 2, if mediation effects were identified in step 1. Y = Intercept + B + e Y = Intercept 1 + b 1 + b 2 + e 1 M = aX + e 2 , Y = Intercept 2 + b 3 + b 4 + b 5 + e 3 . We took and ) the social environment variables as moderators for the significant independent variables in step 3, if no mediation effects were identified. In the final step 4 of the analyses, we regressed physical activity onto the built environment variables and conceptually comparable perceived environment attributes , social environment variables , and when appropriate, the significant socio-demographic variables examined previously as co-moderators . Y = Intercept 3 + b 6 + b 7 + e 4 , Y = Intercept 4 + b 8 + b 9 + b 10 + e 5 , Y = Intercept 5 + b 11 + b 12 + b 13 + b 14 + b 15 + e 6 . All regression models were constructed in three groups . We first tested the mediation effect with the objectively assessed environment as the independent variable and physical activity as the dependent variable. We then took the perceived environment attributes as the independent variable. Next, we examined the health outcomes as the dependent variable. If an effect was not moderated or mediated, we removed the nonsignificant interaction term from the model. We repeated this process until only statistically significant interaction terms remained. We used bootstrap resampling with 95% bias-corrected confidence intervals of the indirect effects. For those independent variables with no significant coefficient, we further explored their associations with the duration and frequency of the physical activity using ordinal logistic regression and nonlinear regression. ( )5 We took and ) the social environment variables as moderators for the significant independent variables in step 3, if no mediation effects were identified. In the final step 4 of the analyses, we regressed physical activity onto the built environment variables and conceptually comparable perceived environment attributes , social environment variables , and when appropriate, the significant socio-demographic variables examined previously as co-moderators . Y = Intercept3 + b6 + b7 + e4, Y = Intercept4 + b8 + b9 + b10 + e5, Y = Intercept5 + b11 + b12 + b13 + b14 + b15 + e6. All regression models were constructed in three groups . We first tested the mediation effect with the objectively assessed environment as the independent variable and physical activity as the dependent variable. We then took the perceived environment attributes as the independent variable. Next, we examined the health outcomes as the dependent variable. If an effect was not moderated or mediated, we removed the nonsignificant interaction term from the model. We repeated this process until only statistically significant interaction terms remained. We used bootstrap resampling with 95% bias-corrected confidence intervals of the indirect effects. For those independent variables with no significant coefficient, we further explored their associations with the duration and frequency of the physical activity using ordinal logistic regression and nonlinear regression. 1) and ), and socio-demographic, perceived environment, and social environment as moderators and ) of the association between objective built environment and health outcomes. The dashed lines and arrows also show the moderated mediation effect ), that is, the potential moderators may influence the mediation effect. 1) and ), and socio-demographic, perceived environment, and social environment as moderators and ) of the association between objective built environment and health outcomes. The dashed lines and arrows also show the moderated mediation effect ), that is, the potential moderators may influence the mediation effect. --- Results --- Socio-Demographic Factors In general, the overweight population was as high as 36% [43]. Only 7.5% of the residents were obese , lower than the national average [44]. The discrepancy was likely due to the younger age of the online sample. Further, one-way ANOVA demonstrated statistically significant differences in health outcomes among individuals, as shown in Table 1. Gender, age, education background, and private car ownership all had significant effects on BMI. Among all participants, 48% were men, who had higher BMI than women and also higher than the normal level . Older respondents were more likely to have higher BMIs, which was in line with previous empirical findings [44]. People with a high school degree or lower education level were overweight. While, gender, age, and private car ownership also had significant effects on physical activity. Additionally, we tested the impact of socio-demographic groups on SoC. We found a bimodal relationship between income and SoC, with both higher-and lower-income respondents having higher SoC, compared to middle-income respondents. Additionally, we found physical activity had impacts on self-reported health status, namely that the MPA frequency duration and the total time of walking related to mental health status. Physical activity can somehow benefit the phycological aspect. Finally, health indicators were significantly correlated with self-reported health status. That is, BMI was associated with hypertension and hyperglycemia , and the SoC had a relationship with mental subhealth . We also found most of the residents were physically and mentally healthy, but up to 19% chose mental subhealth. This index was much higher than the common chronic diseases, like cardiovascular, cerebrovascular diseases, and hypertension, which showed that residents' mental health was also worthy of attention. --- Objectively Assessed Environment Table 2 summarizes the results of the regression model examining the impact of the objectively assessed environment and health outcomes. We found four statistically significant independent variables; land use mix, street connectivity, accessibility, and net residential density. Land use mix and road network density was positively related to the duration of VPA. Additionally, the number of public facilities had a positive effect on the total time of VPA, but weak correlation coefficient. Besides, number of public facilities was also positively related to walking time. In contrast, net residential density had a curvilinear correlation with MPA, and the interpretation rate of the model was the highest among all built environment fitting models . Further, density and connectivity were inversely associated with the sense of community. Density included building density and FAR, and the impact of building density was relatively weak, compared to FAR. As for BMI, the slope was the only indicator that had a significant negative impact. However, no significant relationships were observed between objective and perceived street-level terrain slopes. The perceived and objectively measured neighborhood environment were related but distinctly constructed for unique variance in physical activity in the previous studies [45]. Similarly, we found comparably defined variables exhibited low agreement between each other. That is, the number of facilities, road network density, and FAR had associations with the perceived neighborhood environment but not with the conceptual corresponding one. More specifically, the number of catering, leisure facilities, and public transit stops had associations with the social environment. Road network density and FAR were related to aesthetic and perceived social environment. Therefore, in the mediation test, only FAR was mediated by the social environment with sense of community. However, socio-demographic variables did not show any significant difference in mediation models. --- Perceived Neighborhood Environment Socio-demographic attributes showed a significant difference in the perceived neighborhood environment. Men had a higher perceived neighborhood environment score than women, especially in safety and aesthetics. Those with a high education background showed lower social interaction with neighbors. Additionally, perceived neighborhood environment total score had a positive association with the social environment, implying that residents who perceived higher scores on environment quality tended to have a stronger sense of community. Results of regression analysis about the perceived environment and health outcomes are summarized in Table 3. Only aesthetics and safety had a significant impact on physical activity. Aesthetics was positively related to both frequency and duration in MPA and more frequency in VPA, which was mediated by the social environment. Additionally, safety was related to the total time of VPA. Further, perceived social environment mediated the associations of five out of six perceived neighborhood environment with sense of community, namely connectivity, accessibility, aesthetic, sidewalk, and safety. Finally, we found only connectivity among all the perceived neighborhood attributes was mediated by the social environment on BMI. Although income had no direct effect on BMI, it moderated the effect between connectivity and social environment in the mediation effect. --- Discussion --- Direct Effect of Environment Density and connectivity were positively correlated to physical activity, but the regression coefficient was weak, even statistically significant, which was in line with previous studies [46]. We found road network density had a positive association with the duration of VPA, and the number of intersections was correlated to MPA. This was due to the compact land use that can reduce residents' daily shopping distance, enhance neighborhood commerce, and thus promote residential walking [4]. In contrast, land use mix and connectivity had inverse impacts on sense of community, implying that these two characters had more complicated associations between physical and mental health. Further, the number of parks within the community was related to VPA as expected, because parks in the neighborhood can facilitate engagement in leisure-time physical activity [47]. In addition to the park, this study added other service facilities that might encourage recreational physical activity [48], including gyms, outdoor sports venues, and fitness places, which also showed positive associations. Rather, recreational sports venues contributed to physical activity and were the only elements in the objectively assessed environment that were significantly related to the total time of physical activity, potentially owing to the extension of the activity choice. We additionally took topographic factors into account, especially the hilly terrain. Terrain topography changes in the spatial variability is obvious within the research units. However, slope exhibited no significant associations with physical activity, but negative associations with BMI. That is, respondents had lower BMI in areas with steeper slopes. Further, no mediation or moderation effects were found between slope and BMI, which needs further study on the associations between topography and health outcomes. The evidence for the association between built environment and physical activities comes mainly from self-reported environmental perceptions [16]. Particularly, we found aesthetics to play an essential role between built environment and physical activity. Factors contributing to aesthetic characteristics in our study included night lighting, street trees, pedestrians, architectural aesthetics, natural scenery, and interesting things within the neighborhood. Furthermore, traffic safety had no significant effect on physical activity, but the impact of security safety was significant. What we found was partly consistent with the literature was that not all aspects of safety have a significant impact on PA, namely that security and traffic safety were sometimes not significant, while, the main effect of pedestrian safety was significant [25]. Objectively assessed environment and perceived environment were related, that is, a higher objective walkability score was associated with a higher perceived neighborhood environment score which, in turn, was associated with higher odds of meeting physical activity recommendations [20]. However, our results showed that only land use mix and construction year was significant, albeit inconsistently, correlated with perceived neighborhood environment score. More specifically, industrial frequency density had a negative association while the later had a positive impact, which was consistent with the practical experience; the newly built residential areas had relatively preferable environmental quality, but the adjacent industries would discourage the perceptions of the environment. --- Indirect Effect of Environment Previous studies have found that perceived neighborhood environment mediated the association between built environment and physical activity. In particular, the impact of the number of parks on physical activity was mediated by their perceptual corresponding environment. The effects of intersections and land use mix on physical activity were moderated by gender and safety [19]. Additionally, gender and educational background moderated the effect of perceived safety on physical activity [21]. However, our research found no mediation effect of perceived environment, which was inconsistent with the existing evidence. We found that the number of service facilities was the only objectively assessed environment element significantly related to their perceptually corresponding environment, but there was no mediation effect. Although gender had a significant effect on both perceived safety and physical activity, no interaction effect was found. The possible explanation was that the NEWS scale had a measurement error in a high-density situation. The research confirmed that the social environment in the high-density living environment had important significance in promoting physical activity and sense of community. Sense of community can promote people's awareness of safety, comfort, and self-confidence, thereby stimulating positive physical activities in the community and increasing opportunities for social interaction [49]. Previous study found that low density and abundant commercial land were conducive to sense of community, which can promote leisure activities [37]. Likewise, our findings identified a significant positive impact of sense of community on all types of activities. However, high density negatively affected the sense of community, that might be owing the cramped feelings and lack of green space resulted by high density, which were key barriers to facilitate social interactions. Additionally, residents with positive perceptions of their neighborhood characters have a better social network. Well maintained social relationships contribute to the cultivation of sense of community, which is beneficial to both physical and mental health. --- Strengths and Limitations There are several strengths and limitations to our study. Although great achievements have been made in the study of the built environment and physical activity in the past decades, there is not much research on the high-density environment in China [50][51][52]. The built environment we identified significantly associated with physical activity supported previous studies' findings [9,10,13] and also provided further evidence on Chinese urban environment . We found that both objective and subjective environment were positively related to physical activity which is in line with the literature, but density and connectivity had inverse impacts on sense of community. The study focused on the social environment as the main moderating variable, finding that the social environment had essential significance for physical activity and health outcomes. We confirmed the importance of social environment in the high-density living environment in promoting physical and mental health. However, there were still limitations. First, the study controlled for individual characteristics but did not provide specific analysis of behavioral differences among population groups. Therefore, it would be useful for future studies to distinguish between different demographic groups in the neighborhood with hilly terrain. Second, we only used the buffer method to define neighborhood boundary and made no distinction between the cognitive distance in the questionnaire and the actual buffer distance, which may result in the mismatch between objective and perceived environment. Finally, the demography of the respondents obtained through the Internet survey tended to be younger than the local demography, and the neighborhood self-selection bias of the respondents remained unresolved. Additionally, the sample size was limited to an acceptable range of errors due to the difficulty in data collection. However, the study limited the study population within the central districts and focused on those who had convenient access to public social media, such as white-collar adults in urban centers. The sampling design and data cleaning process also alleviated the concerns related to sampling error. In China's non-first-tier cities, city-level data from authoritative databases is not rich and difficult to obtain publicly, especially those related to personal information and health. For a more comprehensive understanding of the relationship between high-density living environment and health in China, this needs to be further explored. --- Conclusions In general, this study demonstrated that both objective and perceived environment factors had significant impacts on physical and mental health in Dalian. The association of density, connectivity, the availability of service facilities, neighborhood quality with physical activity and/or walking, which has been found to be linked in research in first-tier cities, also holds true in Dalian. Especially, we found that aesthetics and safety play an essential role between built environment and physical activity. This research provides new insights that high density facilitated engagement in physical activity but hindered the sense of community which also had influences with physical activity. Additionally, the objectively measured slope was related to BMI; residents living in the neighborhood with more steep slopes had lower BMI, indicating that the design of slope might be influential. Given the complexity of density in Chinese neigborhoods, especially with hilly terrain, we suggest that future work of this nature might aim to identify to what extent density can facilitate both physical and mental health. This study is also part of an evidence base that social environment is of equal importance, compared to built environment, which needs to be well established by local officials or developers in Chinese communities. --- Author Contributions: Conceptualization, P.S., W.L.; Methodology and formal analysis, P.S., Y.S.; Investigation, data curation and writing, P.S.; Review and editing, Z.G. --- --- Appendix A --- Other Chinese cities Land use mix [9], accessibility [10], neighborhood quality [6], design features and safety [53] density, ingle function, adjacent main road [9] Western countries Land use mix, density, connectivity, accessibility pedestrian infrastructure, parks/squares [12][13][14][15], coasts/hills/sceneries, well-maintained neighborhoods, aesthetics and safety [54] city sprawl, unpleasant vistas, ill-maintained roads and facilities, dirty environment, garbage, broken glass [54]. --- Perceived number of parks Parks on physical activity [19] Gender and safety Intersections and land use mix on physical activity [19] Gender and education Safety on physical activity [21]

Neighborhood built environment may influence residents' physical activity, but evidence of non-major Chinese cities is lacking. We investigated the impact of five socio-demographic characteristics, 10 objectively assessed environment characteristics, eight perceived neighborhood attributes, and social environment on physical activity and health outcomes (sense of community, body mass index, as well as self-reported health status). We also examined (1) five conceptually comparable perceived neighborhood attributes as mediators of the relationship between objective environment attributes and physical activity; (2) other perceived indicators and social environment as moderators of those relationships, using the mediation analysis in regression. Objectively assessed residential density, land use mix, street connectivity, and accessibility were curvilinearly and/or linearly related to physical activity. The slope of terrain was inversely associated with body mass index (BMI). None of the perceived attributes were found as mediators probably due to the weak associations between subjective and objective environments. High density facilitated physical activity but hindered the sense of community. Further, the perceived aesthetic and safety were associated with physical activity. Additionally, social environment moderated the positive associations of all perceived environments (except for slope) and sense of community. The present study demonstrated that both physical and social environment attributes significantly correlated with physical activity in Dalian.

Background Providing cost-effective care for the increasing numbers of complex elderly and/or co-morbid patients is a global problem facing industrialized and non-industrialized nations [1]. With an aging population and individuals living longer lives, healthcare costs continue to rise at rates faster than other parts of the economy [2]. In response, payers have sought to contain spending growth through healthcare rationing and efficiency gains. Exacerbating these challenges are the growing numbers of individuals with chronic disease and multi-morbidities, a proportion of who develop complex health conditions. For example, in Ontario, one study estimated that complex patients constitute 1 % of the province's 13.7 million people but accounted for 34 % of Ontario health care expenditures [3]. Similar research has identified the same trend from the United States [4] and the United Kingdom and Europe [5]. Costs associated with managing complex care patients have generated a growing sense of urgency due to the increasing emphasis on accountability, the sustainability of health care, and pressures posed by population aging. In many jurisdictions across Canada, governments have launched priority initiatives to improve the care costs of complex patients. These initiatives have been based on the assumption that improved coordination will lead to faster care at reduced costs [6]. Often these initiatives have called for researchers to develop innovative models that are both patient-centred and cost effective. Moreover, in Canada, as well as in many other countries, one of the main problems identified in the care of complex patients is poor coordination of services [1]. Poor coordination of services has been described as impeding both good care and efficient use of health care dollars. It has been estimated that in the province of Ontario better integration of care would result in savings of $4 to $6 billion per year from reductions in redundant services, improved coordination and provision of more appropriate services [2]. At the same time that Ministries of Health, health services researchers and media are recommending costsaving measures and creation of new and innovative models of care, those working in social science have been questioning the nature and framing of these public policy debates. Many have challenged the hidden assumptions underlying the import and application of performance measurement and accountability principles developed in business settings into health care settings [7][8][9] and have sought to draw attention to the implications of the resultant discourses that are shaping public policy debates. They have, for example, challenged the "virtual realities" created by systems of accounting based on administrative databases [7][8][9] that produce this notion of "high users" of health care resources cited above. Nevertheless, these debates are often not well-integrated into mainstream conversations about health policy and practice [10]. In this context, our study builds on an innovative Canadian Institutes of Health Research funded research program that uses a social science lens through which to view the organization of the care of patients with chronic osteoarthritis pain, many of whom have multiple co-morbidities [11]. It is clear that that there is a need for such research as this is where the majority of patient care takes place and is seen as a key determinant in complex patients' need for care [12]. Moreover, this research also seeks to explore how other stakeholders are involved in coordination of care not as separate objects of study but as part of the same patient care "system". This will be accomplished by speaking with primary care physicians and asking them to describe both what they do and who else is involved in the care they deliver to patients with multi-morbidities and chronic pain. Complex patients are the focus of much debate and concern in the contemporary healthcare context. They are defined as those who have more than one of the following five major chronic conditions: arthritis, diabetes, heart disease, chronic lower respiratory tract disease and stroke [13]. Patients with these chronic conditions may also suffer from mental health problems or addictions [13]. Multi-morbidity is even more important as each condition may influence the care of the other condition, result in interactions between therapies and/or direct contraindications to therapy and thereby limit life expectancy [14]. At the patient level, multi-morbidity has been found to affect quality of life, ability to work, disability and mortality [15]. In addition, the process of navigating care across different specialists is burdensome for patients [16] and is a patient safety issue [3]. Our previous work in patients with osteoarthritis pain suggests discordance between the policy goals of improving patient care and the experience of patients [17,18]. Arthritis, specifically OA, is one of the most common, disabling, and costly chronic diseases [19][20][21]. It is a degenerative joint disease that most commonly affects the knees, hips, hands, and spine and is characterized by a slow evolution of symptoms and disability over time [22][23][24]. Arthritis is the most frequent cause of chronic pain which is debilitating to the individual and extremely costly to society. Primary care is most often the first contact for people seeking symptom relief. Truly interprofessional care is necessary to provide appropriate evidence-based pain management and self-management support for these patients who are seeking appropriate strategies to ameliorate and limit progression of their chronic pain and resultant disability. Yet achieving successful IPC often remains an elusive goal in practice [25]. Several research gaps have been identified in relation to primary care in musculoskeletal care, including OA [26]. These include well-known issues such as a lack of comprehensive management that includes exercise and weight loss strategies [27], a focus on other chronic conditions or co-morbidities that may be considered more urgent [28,29], and low referrals rates to both physiotherapy and total joint arthroplasty [29]. There are also ongoing controversies associated with the use of opioid medication to manage pain and concerns with possible medication dependence, misuse, and addiction [30][31][32]. Finally, at the patient level, there are many socioeconomic factors that influence help-seeking, referral, and treatment, with some patients "falling through the cracks" [33]. However, despite our knowledge of these various gaps, what remains unknown are strategies or models of care that, while rooted in primary carethe "medical home" for most patients [34] are coordinated effectively with other care providers, policymakers, patients, and their families and offer the benefits of IPC. Primary care is the context for most OA education and management. The role of context in health care has been increasingly recognized as important at the local level [35]; however, context is often described in abstract terms and may refer only to a description of geography or place [36]. The need to investigate the empirical context of the primary care setting, not as it exists in isolation or in the abstract, but as it pertains to other providers in the patient journey is critical in order to improve patient care of OA pain management. This will allow for an exploration of how primary health care isor could be better-integrated with other services that play an important role in health, such as housing, education, and income. The patient-centred medical home has been introduced as a chronic care model that can reduce costs [37]. It emphasizes the need for "care management" to be based in primary care and has become increasingly important in Canada as well as internationally [38]. Several studies of care management in primary care show convincing evidence of improving quality [39][40][41][42][43][44][45]. These studies measured a variety of quality outcomes, including patient satisfaction, functional ability [capacity to perform basic activities of daily living], mortality, bed disability days and overall quality of life. The results of care management studies in primary care are mixed regarding reductions in hospital use and healthcare costs. All of these studies enrolled patients with multiple chronic conditions who were at high or moderate risk of incurring major health care costs. Each program placed substantial emphasis on training the care manager team, keeping care manager panel sizes at reasonable levels, forging a close relationship between care managers and primary care physicians and including care manager interactions with patients in-clinic, and at home by telephone. This study will employ the approach of institutional ethnography to investigate how primary care physicians define, encounter and manage complex patients who experience chronic pain. Our overarching research question is: How do primary care physicians describe the work they do in caring for patients with complex chronic pain conditions? This question will become our starting point, rather than the end point, to allow our team to explicate how care is put together at the level of the institution with attention to how care is coordinated in local practice . Using an expanded definition of work will allow us to understand the many types of work that physicians do and also alerts us to how the discourses and concerns of institutions enter into the everyday language of care providers. This will achieve the following specific objectives: 1. Describe carefully and empirically the work that goes into caring for complex patients with chronic pain and multi-morbidities beginning from the standpoint of primary care physicians and working outward to capture the often invisible social relations informing patient care; 2. Follow in each setting the textual, informal and formal practices implemented by the providers, as their work is coordinated with that of others in different settings. This will create a "map" of the social relations of primary care provision of OA chronic pain management that includes the perspectives of all key stakeholders and will allow for the creation/augmentation of new models of care that are effective, efficient and sustainable, ultimately improving the patient's experience of CARE. 3. Provide a link between everyday experience to broader discourses related to health care system inefficiencies, integration and patient-centred care. These links will be the mechanism by which findings from our work can be " replicated" and applied to other provinces and internationally. --- Methods Institutional ethnography was developed by sociologist Dorothy Smith [46][47][48][49][50]. According to Smith, the social strategy she developed is "constrained by the project of creating a way of seeing, from where we actually live, in the powers, processes and relations that organize and determine the everyday context of that seeing" [50]. IE refers to an approach to inquiry rather than a set of methods. It uses people's everyday experiences as the starting point for an exploration of the often invisible social relations that underpin or organize their experiences [47][48][49][50]. Based on Smith's understanding of the social organization of knowledge, it allows for an examination of the complex social relations organizing people's experiences of their everyday working lives. IE makes use of several types of data, typically including interviews, observations and texts. However, IE studies may differ in the extent to which they employ the various data collection strategies [50]. In this study we will rely on interviews and texts and also observations when possible. Ethics approval for this study was obtained through the University of Toronto Research Ethics Board. --- Sampling and recruitment : year one Understanding the social world requires taking up a specific position as a starting point from which to begin to explore how things are put together the way that they are [50]. In this sense, IE is sampling an institutional process rather than a population. All qualitative sampling is purposive rather than experimental and there are multiple purposive sampling techniques [55]. The goal is not to be representative of the broader population, but rather to understand a phenomenon or process in-depth. In practical terms, our study will include any primary care physicians working in community and academic hospitals and in any type of primary care organization, such as family health teams, solo practice, and Community Health Centres. We will purposively select family physicians from each type of practice model within 4 Local Health Integrated Networks , one northern, one southwestern, one downtown Toronto and one eastern, and within each we will select academic and community hospitals. Participants will initially be identified through members of our team [who in turn are linked to other collaborators across different sites] as we embark on our study. Following REB approval, the principal investigator will send out an email with a letter of information and a consent form requesting that the recipient participate in an interview in a location of their choosing and at a date and time convenient to them. At the conclusion of each interview, participants will be asked to suggest other potential participants whom they identify as being involved in the coordination of their working lives . In an IE study, sampling, while purposive, does not follow standard strategies such as maximum variation or theoretical sampling [55]. The identification of research sites, informants and texts cannot be pre-determined but proceeds through the process of inquiry [53]. For example, primary care physicians refer patients for joint replacement surgery and then care for them post-surgery. We might therefore speak to those involved in the referral and repatriation process, including orthopedic surgeons and pharmacists. This is known as snowball sampling [55]. IE researchers follow sequences of action, with one informant's interview leading the way to the next or to a text for analysis. --- First level data collection: interviews We estimate that we will conduct approximately 80 interviews over 18 months. Estimates of qualitative interviews are classically difficult to determine prior to entering the field given the exploratory nature of the IE approach. Therefore, our estimate is based on presupposing that at a minimum we might interview 5 primary care physicians across 4 different sites and/or settings . We may interview a greater or lesser number of these participants depending on what they share with us, we might interview the same informant twice, and may also interview others who we have yet to identify as playing a key role in the social coordination of chronic pain management. In addition and as previously noted, IE researchers look for something outside of the experiences of key informants which is largely invisible to them and yet that enters into and coordinates their work with those of others of whom they ma y not even be aware. Exploring relations beyond primary care physicians' experience means learning from others who work in related settings. Hence, we will also interview other health care providers, policymakers and patients, and their family members. These interviews will take place in a location that is convenient for the participants and formal written consent will be obtained. The content of our in-depth interviews will be guided by an emphasis on the actual work that people perform. Most research-based descriptions of physician decision-making are abstract accounts that are not connected to the actual work they engage in [34] or refer to individual psychological explanations for physician behavior [12,35,36]. This concept of work and of work knowledge is what the ethnographer draws on in talking to informants and will comprise the content of the interviews. This also opens the possibility of exploring informal aspects of work that are rarely accounted for in professional practice guidelines and of analyzing the role of texts and writing in the work physicians and policymakers perform. --- Analysis The procedural steps involved in analyzing data are similar to that practiced in other qualitative research approaches. Data is transcribed and coded so that it can be analyzed. Codes identify features of the data that are pertinent to the research questions and organize data into more concise ideas that can be eventually grouped into topics. They are often recurrent keywords or concepts that are supported by interview data . Coding of the first few transcripts will be performed by the P.I., the interviewer and another member of the research team. Multiple coding is a useful way of developing reflexivity rather than a tool to confirm the "truth" of the data [57]. Reflexivity used in this way refers to the process by which we critically examine our own assumptions about the world [57]. Through comparison of our developing understanding of the transcript data, each member of the coding team has an opportunity to check their own assumptions and ideas. The closest equivalent for this type of analytic technique would be thematic analysis [58,59]. However, codes as they are used in IE are not used to develop themes but will reflect our analytic interest in explicating how the work that is performed by an actor in one situation is coordinated extra-locally. Finally, we will also hold team meetings in which we will discuss and reflect on our emerging understanding of what is being described. The thoughts and comments that result from all meetings will be recorded as extensive marginal notes throughout the interviewing, transcription, and coding phases, with the goal of focusing thoughts around the emerging concepts. These meeting notes also become part of the audit trail in which the team keeps careful track of all interpretative and theoretical decisions that are made about the phenomena being studied. --- Second-level data collection: year two Text and discourse analysis Through interviews and also drawing on our own institutional knowledge, our team will identify a series of texts and discourses that are present in the language of participants as they describe their everyday work practices in caring for complex patients. Texts refer to any document that has a fixed and replicable character and includes any documents that can be become distributed and subsequently used by users in different places and at different points in time. Texts are "activated" when they are read, completed or filled in . Higher order texts [52] are those that are not often visible in local settings but become active in the actual settings of people's work. An example of this would be the Wait Times Strategy. These higher order texts do not rule by prescription but by establishing the "concepts and categories of which what is done can be recognized as an instance of expression of the textually authorized procedure" [54]. Texts then both standardize and mediate social relations [52]. Our interview data will be analyzed for "clues" that point us to texts, which may help us explain organizational details missing from experiential accounts. The genre of text that participants identify cannot be pre-determined but may include policy documents, related to different sectors, such as education or health or clinical documents such as care pathways. For example, an interviewee may make passing mention of "filling out Form X in order to accomplish Y," which we would then follow up by tracking down Form X and any associated governing policies [38]. Tracking a document across various sites helps to create a social "map" of the various work processes involved in coordinating a particular model of care. The documents we seek will be publicly available texts. We will assemble the various documents that may play a role in care coordination between primary care physicians and other professionals and across sites in order to better understand the individual accounts being provided to us. Our preliminary work has led us to identify the several key documents as being central to our analysis but others will be added during the course of our interview. Textual analysis will also include analyses of relevant discourses. Our use of the term discourse draws on the idea that language is active; that is, it has a constitutive function as well as a descriptive one [46]. In our work we will analyze the use of several terms in everyday language used by physicians, other clinicians and policymakers in order to better ask: What is left out by the use of these terms? Who benefits from these terms? What is rendered invisible? Explicating a social process: year three In the third year of our study, we will begin the process of mapping the social relations informing care. In many research traditions this is described as "triangulation". The key difference however between a positivist use of the term "triangulation" and most critical qualitative research approaches is that the purpose of the activity is not to validate a truth claim but rather to extend our understanding of a phenomenon. Starting with insights gained from interviews we will identify "active texts" to discover how these texts are used in the work of primary care physicians and that coordinate this work with the work of others in different settings. We will also be mapping how the consciousness of individuals is coordinated with those of others. For example, how do the discourses of efficiency, integration and patient-centered care enter the talk of primary care physicians when they are describing their ever yday work caring for complex patients with OA pain? Does these terms map to a higher order text? Data management and steps to ensure quality All interviews will be audiotaped and transcribed. Transcripts will be entered in NVivo software program for data management. It should be noted, however, that while NVivo is useful for managing large qualitative data, it does not perform analysisthis will be undertaken by the researchers. Quality in qualitative research is evaluated differently from the criteria used in quantitative studies. While this is an area of some controversy, a number of strategies will be employed to enhance the trustworthiness of the findings [54][55][56] including recursive questioning during the interviews and audit trails. In much research, the researcher's presence is treated as a bias that must be overcome [52]. As Smith [51] notes, an IE does not rely on notions of objectivity in order to produce "validity". However, it does strive to produce accounts that are accurate representations of how things actually work. Smith stresses the importance of remaining "faithful to the accounts provided by people of their lived experience while going beyond that experience to explicate how that experience happened as it did" [51]. With this in mind, most qualitative researchers speak of authenticity and reflexivity as central to the goal of "getting it right". We will make good use of the multi-disciplinary nature of our team to enhance our reflexivity as the diversity of our group will provide many opportunities to challenge our own and others' assumptions as we proceed through the stages of data collection and analysis. --- Discussion The "underdevelopment" of relationships between sociology and other disciplines as well as between healthcare organizations has been long noted [10]. Yet there is growing recognition of the potential and need for research that brings together perspectives from a range of disciplines [46]. For example, current knowledge translation frameworks and empirical research in implementation science [34] cite context as the critical consideration in the effective integration of research evidence into practice. However, there remains a dearth of knowledge about how to define, measure, or engage with context [47]. On the other hand, the notion of "situated knowledge" is common amongst many sociological traditions and is well described, used and applied [48]. It is our belief that context and situated knowledge may well be referring to the same phenomenon. In order to empirically study situated knowledge, we may thus borrow from sociological research traditions. Studying the health care institution as it is experienced at the level of people's everyday work means being able to see it "in motion" [9] and to explore how various texts and competing discourses inform our understanding of the increasingly complex healthcare environment. Through their work, IE researchers are helping to redefine the problems, rethink the questions and design and conduct studies that explicate how things actually work in practice [9]. --- Conclusion Few studies have been able to adequately capture or address the complexity of the care environment in which primary care operates in relation to many other specialties, diseases and diverse patient populations. Our study is novel in that it aims to ground itself in a particular standpoint, not to focus on individual subjective experiences or meaning, but to begin to locate the social coordination of the work of primary care physicians as it is provided in and across both community and academic health care settings. Based on primary care physicians' responses we will begin to identify the various other provider groups involved in patient care delivery for complex patients, both directly and indirectly, and during a second wave of interviews we will speak to them. This will allow us to identify how the work of coordinating care across multiple settings is accomplished, in practice as well as discursively and textually. Focusing on patients with chronic OA pain will allow us to be specific in our questions, while building on our previous work with chronic pain patients. Further, it renders our study manageable. In a sense, the OA patients will provide the case study for our exploration. However, as in keeping with the exploratory nature of this approach, we will remain attentive and open to physician accounts of other complex patient groups. Our goal is to map an institutional process of providing care that may be similar and therefore useful across many disease groups. Our study is poised to make a significant contribution to our understanding of interdisciplinary, inter-professional and community-based partnerships. An expected outcome of this study will be the development of new, or augmentation of existing, models of care, that are based in the local realities of primary care practice. --- Trial status We are currently in year one of this project. Key informant interviews have been conducted and transcribed, but have not yet been analyzed. --- --- Competing interests The authors declare that they have no competing interests. --- --- Authors' information

Background: Patients with chronic conditions and multiple comorbidities represent a growing challenge for health care globally. Improved coordination of care is considered essential for providing more effective and cost-efficient care for these patients with complex needs. Osteoarthritis is one of the most common and debilitating chronic conditions, is the most frequent cause of chronic pain yet osteoarthritis care is often poorly-coordinated. Primary care is usually the first contact for patients requiring relief from chronic pain. Our previous work suggests discordance between the policy goals of improving patient care and the experience of osteoarthritis patients. We plan to investigate the empirical context of the primary care setting by focusing on primary physicians' conceptualizations and performance of their work in treating complex patients with chronic pain. This will allow for an exploration of how primary health care isor could beintegrated with other services that play an important role in health care delivery. Methods: Our study is an Institutional Ethnography of pain management in family medicine, to be carried out in three phases over 3 years from 2014/15 to 2018. Over the first year we will undertake approximately 80 key informant interviews with primary care physicians, other health care providers, policymakers and clinical experts. In the second year we will focus on mobilizing our networks from year one to assist in the collection of key texts which shape the current context of care. These texts will be analyzed by the research team. In the final year of the study we will focus on synthesizing our findings in order to map the social relations informing care. As is standard and optimal in qualitative research, analysis will be concurrent with data collection. Discussion: Our study will allow us to identify how the work of coordinating care across multiple settings is accomplished, in practice as well as discursively and textually. Ultimately, we will identify links between everyday experience of care for patients with chronic pain, and broader discourses related to health care system inefficiencies, integration and patient-centred care. An expected outcome of this study will be the development of new, or augmentation of existing, models of care, that are based in the local realities of primary care practice.

Background Since the declaration of Millennium Development Goals, there has been an increased attention on women's health in healthcare research and policymaking. As a key indicator of international development, MDG 5 was dedicated to the reduction of the maternal mortality rate by 75% by 2015. However, progress towards achievement of this goal has been inadequate, a mere 34% decline since 1990, and yet uneven across different world regions [1]. According to WHO, the developing countries, especially those in Sub Saharan Africa and Asia share a discriminate burden of maternal mortality , which remains the second largest cause of mortality among women of reproductive age in these countries. With about 85% of global population, developing countries altogether account for about 99% all maternal mortality cases [2]. Moreover, about 97% of all unsafe abortions occur in LMICs which contributes to about 15% of total maternal mortality in these countries [3]. Statistics on the utilisation of maternal health services is equally disheartening. In the developed world about 98% women receive adequate number of ANC services, and skilled birth attendants supervising 94% of the deliveries [4]. In the LMICs in contrast, about half of all women remain deprived of adequate ANC services [5]. Two broad perspectives from which researchers attempt to explain this stark difference include the efficacy of healthcare systems such as quality, access and infrastructural barriers [6,7], and proximate determinants such as economic, gender, health behaviour and sociocultural barriers [8,9]. Among the themes that commonly emerge in the sociocultural context of reproductive health, violence against women [10], and male involvement [11] have been two very important and challenging ones. In this study, we focus on male involvement and aim to explore the factors associative factors among men in Bangladesh. The issue of male involvement in reproductive care was first pronounced officially in a conference on Population Development in Cairo held in 1994 [1]. Since then the number of empirical studies and demand for contextual evidence on sexual and reproductive health seeking behaviour and their determinants have also grown considerably. Research evidence from other South Asian countries suggests that men's involvement in women's reproductive care has a crucial role to play to increase the uptake of maternal health services and reduce maternal and infant mortality [12][13][14]. Reproductive health seeking behaviour of an individual has shown to be a psychological construct affected by various proximal/individual [12,14,15] and distal/social influences [16,17]. There is also lot to accomplish especially in the areas of universal access to reproductive health services, increasing the rate of institutional delivery and adoption of family planning which have shown to be more effective in active presence of male counterparts [15,18]. In addition to the rate of utilisation of maternal healthcare service, male participation is also positively associated with pregnancy outcomes. Prior studies have shown that male involvement was significantly associated with reduced odds of postpartum depression and improved utilisation of maternal health services [6]. In the predominantly patriarchal society as seen across the South Asian region, women in Bangladesh are generally dependent on male counterparts for making decisions on matters as general as their own and children's healthcare, household purchases and visiting relatives [15]. Being faced with household power imbalance and having minimized control over resources would generally necessitate for even greater involvement of men in women's health issues. Apart from that, the longstanding sociocultural view on sexual and reproductive health is directed in a way that negatively affects reproductive health communication between partners and understanding each other's positions regarding such matters [19,20]. The depth of perception of reproductive health needs among men and women and their SRH seeking behavior are strongly influenced by the established meanings of reproduction embedded in the society in which they live [21]. In a qualitative study conducted on a group of Bangladeshi men, participants reported feeling uneasy to discuss reproductive health and STDs related issues with their wives, accompany them to healthcare centres and avoided dealing with reproductive health related complications with service providers [20]. Similar studies conducted in other countries have suggested in-depth population based studies to explore the underlying causes of inadequate participation of men in reproductive health. However, studies on this topic in the context of Bangladesh is remarkably scare. To this end, we conducted this research with the intention to enrich the literature and facilitate policy making aimed at promoting male involvement in maternal health in the country. --- Methods Data source, study area, and sampling procedure We used the sixth round of Bangladesh Demographic and Health survey data for this study. The data is nationally representative, cross-sectional in nature, and carried out in 2011 from July 8 through December 27. Data were sourced from the official website of DHS . The National Institute of Population Research and Training , a renowned health research organization in Bangladesh [22], conducted the survey. The survey is a part of the International Demographic and Health Survey program known as MEASURE DHS, which is currently active in about 90 countries, and conducted under the auspices of the United State Agency for International Development and technical assistance of ICF International of Calverton based in USA. The survey employed a two-Stage cluster sampling method covering the population residing in noninstitutional settings in Bangladesh. The two-stage clustering of the population involved labelling the smallest administrative units as enumeration areas or clusters, each consisting of households at mouza or mohalla level. Firstly, selecting EAs based on their size proportional to that of the units. Secondly by selecting household systematically from each EA to ensure effective sampling. BDHS 2011 selected 600 EAs, however only one third were selected for men sample. In total 4,343 men were found eligible for the survey among which 3,997 were finally surveyed . More details regarding ethics protocol on biomarkers used in Demographic and Health surveys are available at: http://goo.gl/ny8T6X. --- Subjects Study subjects were male participants ageing between 15 and 69 years. In total 1196 men were finally included in the analysis. --- Variables Level of activeness of male involvement in reproductive care was the response variable in this study. In order to select the potentially relevant covariates in the context of male involvement in reproductive health, an extensive literature review was conducted surrounding the most proximal themes: demographic and socioeconomic factors and media use status [23,24]. Secondly, based on the availability of variables in the dataset, the following items were selected for analysis: Age, type of residency, religion, educational attainment, type of occupation, level of earning, sex of household head, number of members in the household, interaction with CHWs and in community health events, and media use . --- Measurements Male participation was measured based on answers to a composite scoring on three items : knowledge , awareness , and practice . Each correct/positive answer was assigned score '1' , and '0' if incorrect/negative. Total score ranged from '0' to'12. Based on the contrast between individual scores and population mean scores, male involvement were dichotomized as active , and passive [23]. Age was trichotomised into 3 groups: 15-29 years, 30-44years, and 45-64years. Place of residency was categorized as rural and urban. Religion was categorized into Islam '1' and others '0' . Educational attainment of participants were categorized into three groups based on the total number of years of receiving formal education: 0 = Nil, 1 = Primary , 3 = Secondary /Higher . Type of occupation was categorized in the following way: 1) Farming = Farmer, agricultural worker, fisherman, poultry farmer, cattle raising; 2) Blue collar jobs = carpenter, mason, driver, construction worker, rickshaw puller, brick breaking, road building; 3) White collar jobs = Businessman, physician, lawyer, accountant, teacher, government service holder. Utilization of paper and electronic media has been shown to be associated with reproductive health behaviour. This study included three types of media use: TV, listening, radio, newspaper; and was dichotomized flowingly: 0 = not using at all, 1 = using occasionally/ regularly. --- Statistical analysis The first step in the data analysis was descriptive statistics. Percentages of study population across the independent variables were calculated. Cross tabulation was performed to identify the independent variables of significant association with the level of male participation. Significance of associations was estimated by χ 2 -test. Only the variables, which showed statistical significance in χ 2 -test were retained for regression analysis. All the explanatory variables were entered simultaneously into the regression model. Data were adjusted for sampling weight and for clustering effects. We performed intraclass correlation analysis prior to choosing appropriate regression model. As ICC value was found insignificant, multiple regression method was performed. Finally, we conducted binary regression analysis to sort out the variables which significantly impacted male participation status in reproductive care [25,26]. Results of the regression analysis were reported in terms of p-values, odds ratios and 95% confidence intervals. p-value less than 0.05 was considered statistically significance in all cases. All analyses were performed using SPSS version 20.0 for MAC . --- Results Table 1 shows the frequency and percentage of correct answers by participants regarding reproductive issues. Majority of the men had correct knowledge about requirement of food and necessity of check-up during pregnancy . Only 23% of the men knew the correct timing of first check-up during pregnancy. Regarding contraception, almost half the men were of opinion that reproduction is women's issue and does not concern men. Almost half of the men said that they did not have any idea whether or not wife visited any health facility or was visited by a medical person. However, 70.2% of them knew if wife received antenatal check-up for during pregnancy. About onethird of the participants reported being present during visit by a medical person and 71.2% present during delivery of the last child. 55.6% men discussed about medical persons with wife and about one-third communicated with medical persons himself. --- Baseline information regarding the study population Table 2 outlines the basic characteristics of the study population . About one-third of the participants belonged to the age group of 30-44 years and more than three fifths were of rural origin. 88.9% of the sample population were Muslim which is almost the same as observed at country level . Almost twothird of the participants completed secondary school while one-fifth received no formal education. 28.1% of the sample consisted of farming population. Proportion of both blue-and white-collar professionals were more one-third of the total sample population, however only 12.1% of the total sample reported earning sufficient income to support family. More than a quarter of the sample reported having insufficient income level. Almost all the participants were from male-headed households and more half of had 5-8 members. About half of the total participants reported having the habit of reading newspaper. Percentage of respondents watching TV and listening to radio were 92 and 16.3 respectively. Only about a quarter of the subjects reported ever hearing about family planning. Among the three media of information regarding family planning included in this study; poster, billboard and leaflet combined were the most popular compared to community health workers and community events . Almost all the explanatory variables were found be significantly associated with the level of involvement in reproductive healthcare and were retained for final regression analysis. Mean score was of male involvement 5.7 ± 2.2. The results show that only 40% of the participants were actively involved in women's reproductive matters. The variables, which were excluded from regression analysis, are age, religion, number of household members and utilisation of radio. --- Factors associated with active involvement of men in women's reproductive health matters Table 4 shows that male involvement was significantly associated with type of residency, level of education, reading newspaper and learning about FP from community health workers. Type of occupation, sex of household head, watching TV, listening to radio, learning about FP from community activities were not significantly associated with active involvement. Results illustrate that participants with formal education were more likely to have active participation in reproductive care compared to those with no education. Men who read newspaper were twice as likely to have active involvement. Though learning about FP from community events and poster/billboard media were found be to be associated with male involvement in Chi-square test, it showed no significant impact in regression analysis. However, odds of active involvement were also twofold among men who learned about FP form CHWs. --- Discussion and policy recommendations Results of this study showed that only 40% of the men had active involvement in reproductive care, and knowledge and awareness regarding reproductive health was remarkably low. Though most participants knew that women need institutional care during pregnancy, knowledge about timing for pregnancy checkup, contraception and awareness about utilisation of MHS by wife and rate of physical presence in service utilisation was meagre . This result is not surprising given the result that one-fifth of the participants had no formal education and only 14.5% attained secondary or higher level education . Previous studies have reflected on the importance of husbands' education on positive reproductive health behaviour [11,22,27]. Poor knowledge concerning SRH is also shown to be associated inadequate communication about reproductive matters among family members and grow a virtual barrier for cross-gender cooperation thereby [28]. Conversely, better communication on SRH has positive impacts on reproductive health awareness [29]. Findings of our study suggest that literacy has a crucial role to play in ensuring male involvement in reproductive care which is consistent with prior studies conducted in other south Asian countries [27,30,31]. In Bangladesh, the reserved view towards SRH matters exist largely because there is not enough political incentive and civil society motivation to create room for the subject in the tradition health belief systems. Programs aimed at promoting male participation in reproductive must focus on systematically addressing the social barriers in a culture friendly way to ensure effectiveness and long-term success. Type of residency also appeared to be a significant determinant of male involvement in reproductive care. The urban-rural divide regarding reproductive health behaviour is explainable by the fact that people in urban areas tend to have higher literacy and socioeconomic status, enjoy better access to healthcare service and receives greater media exposure, all of which are likely to improve health behaviour in general [32,33]. In our study, men who reported having the habit of reading newspaper occasionally or regularly had higher participation in reproductive care. Therefore, newspaper coverage of reproductive health information is likely to generate potential benefits. However unexpectedly, we didn't find any association between electronic media exposure such as TV and radio. This may be due to the increasing number of mobile phone subscribers, rapid expansion of internet and social networking sites, which made the traditional media less interesting especially among urban residents. Despite that, TV and radio programs remain a source of entertainment and pastime for many. In China, watching television was found to be strongly associated with adoption of modern contraceptive methods and the number of children desired [33]. As the population in Bangladesh is predominantly rural, the media sector should take innovative actions to design TV/radio entertainments more interesting and effective by incorporating health messages into age specific programs to encourage positive attitude towards reproductive health. Another important contribution of our study is that it found a positive correlation between communication with CHWs about FP programs and male involvement in reproductive care. In Bangladesh, CHWs occupy a crucial position in the continuum of healthcare providers especially in remote areas as the country faces huge human resource deficit in healthcare and poses challenges to meet the population health needs [34]. Involvement of CHWs has proven the potential for cost-effective services in areas as critical as maternal and neonatal care [35] and DOTS for tuberculosis [36]. However, their potential remains far from being fully developed and exploited especially in the domain of reproductive care services. Apart from providing direct healthcare services, CHWs can play a vital role in implementing strategies for changing attitude towards reproductive health in both men and women. Feeing of confusion and embarrassment in physician-patient communication is a common thing while discussing confidential matters among young patients. CHWs can bridge the gap substantially since they are usually recruited from the same environment. As they already have some degree of understanding and intimacy with the local populace, people have the advantage of expressing themselves more easily and thus creating the climate for positive attitude and behaviour towards reproductive health [29]. Results also indicate that men who learned about FP from CHWs are more likely to be involved in reproductive care which is consistent with the prior studies showing the association between SRH education and positive attitude towards reproductive health behaviour [20,37]. Bangladesh government has made several programmatic efforts to enhance community-based educational intervention programs to promote maternal and infant health. However, such programs to enhance reproductive health knowledge would require a different approach to ensure participation of both men and women. Educational programs targeting women's health education were found to be effective in improving their knowledge Besides its contribution to the current literature, this study has few mentionworthy limitations. Firstly, we used secondary data, which meant that we had no control in selecting the variables and the way they were measured. Secondly, male involvement was measured in terms of performance on knowledge, awareness and practice levels which are subjective matters and prone to misreporting by the participant and hence may not represent the actual scenario. The DHS survey was conducted in 2011, and prevalence of several factors might have changed since then. --- Conclusions The factors that can influence the degree male participation in reproductive care can vary according to the sociocultural environment in which individuals live and interact. Based on a nationally representative data DHS in Bangladesh, our study concludes that educational and community level factors play important roles in male involvement in the country. Given an understaffed and underfunded healthcare system, it is suggested that policy makers pay special attention to organizing health education campaigns through engaging CHWs targeting men especially in rural areas to improve knowledge and attitudes towards reproductive care. --- Availability of data and materials BDHS datasets are available through the website http://dhsprogram.com/. --- Abbreviations CHWs: Community health worker; DSH: Demographic and health survey; FP: Family planning; MHS: Maternal health services; MMR: Maternal mortality rate; SBA: Skilled birth attendants; SRH: Sexual and reproductive health --- --- Competing interests The authors declare that they have no competig interest. --- ---

Background: Men's active involvement in reproductive healthcare has shown to be positively associated with maternal and child health outcomes. Bangladesh has made appreciable progress in its pursuance of maternal mortality related goals in the framework of the MDGs. However, there remains a lot to be accomplished to realise the long-term goals for which active participation of male counterparts in reproductive care is crucial. Therefore, the objective of the present study was to investigate factors associated with male involvement in reproductive health among Bangladeshi men. Methods: We used data from Bangladesh Demographic and Health Survey (BDHS) conducted in 2011. Study participants were 1196 married men, aged between 15 and 69 years and living in both urban and rural households. Level of male involvement (outcome variable) was measured based on the responses on knowledge, awareness and practice regarding reproductive health. Chi-square tests and multivariable logistic regression models were performed for data analysis. Results: Out of 1196 participants, only 40% were found to be active about partners' reproductive healthcare. Chi-square test showed significant association between active involvement and ever hearing about family planning (FP) in television, learning about FP through community health events, community health workers and poster/ billboard. Results from logistic regression analysis revealed that type of residency [p = 0.004, AOR = 0.666, 95% CI = 0. 504-0.879], literacy [secondary/higher education-p = 0.006. AOR = 0.579, 95% CI = 0.165-0.509], learning about family planning from Newspaper [p < 0.001. AOR = 1.952, 95% CI = 1.429-2.664], and television [p = 0.017. AOR = 1.514 95% CI = 1.298-1.886], and having been communicated about family planning by community health workers [p = 0. 017. AOR = 1.946, 95% CI = 1.129-3.356] were significantly associated with active involvement of men in reproductive health issues. Conclusions: Level of male involvement was associated with schooling experience, type of residency and exposure to electronic media. National health policy programs aimed at promoting male involvement in reproductive care should focus on improving knowledge and awareness of reproductive health though community health education programs with a special focus in the rural areas.

Introduction Sharing humors in social media is now a digital phenomenon. Humor, a fundamental aspect of memes, typically elicits laughter and induces feelings of wellbeing among individuals [1] . Although it is often described to be a positive form of communication, humors become a gateway for gender stereotypes in social media. Humor often relies on stereotypes as a foundation, which can potentially perpetuate detrimental social norms [1,2] . This aspect raises concerns regarding the potential negative implications associated with such humorous portrayals. Hence, this study wanted to describe how gender-based humors in social media can impact gender mainstreaming campaigns. Essentially, this study aimed to describe possible mechanisms that delimit the mainstreaming of gender sensitivity initiatives. In line with the direction of this study, linguistic imbalances are important to study because it gives understanding on the concept of inequalities and imbalances in the society. This study focused on the dynamics of language use in social media which requires in-depth theoretical and narrative analysis. The incorporation of humor has been observed to play a crucial role in the communication strategies employed by digital users, thereby significantly enhancing the potential of their messages to achieve viral status [3] . The prevalence of online memes primarily revolves around the depiction of popular culture and everyday experiences, with a notable emphasis on themes related to sex and gender [2,4] . Stereotypes play a significant role in humor as they serve as crucial markers for the construction of in-group identity and the establishment of social boundaries [2,5] . In the initial study conducted by Chavez and Del Prado [6] , social media users thought that "it is normal" or "it is part of our lives" highlighting the normalization of gender-based humors in social media. In certain cases, the judgment of normalization, has been shown to correspond with the perceived severity of their content, such as the degree of harshness, insensitivity, and potential for causing emotional distress. Consequently, language and social norms are barriers for gender mainstreaming because people reiterate social distinctions and beliefs [6,7] . Women are often victims of sexist humor in social media [8] . Women are frequently subjected to stereotypes and media portrayals that depict them as exhibiting irrationality, dependence, weakness, and emotional instability in comparison to men. Consequently, men are often perceived as the more legitimate and dominant participants in social media [9,10] . It is worth noting that the stereotypical depiction of women in online can potentially contribute to the perpetuation of the "patriarchal ideology of women as enemies" [11] and the notion of "women who hate each other" [10] . The memes appear to have a notable impact on promoting or, at the very least, cultivating a disposition of acceptance towards sexism, as they effectively diminish the perception of its harmfulness, derogatory nature, or offensiveness [2,8] . In cultivation theory, individuals who are exposed to various forms of media tend to interpret and perceive social realities based on the way these realities are portrayed within the media landscape [12] . In early cultivation studies, televisions have a stabilizing effect on societal patterns, leading to a propensity for resistance to change [12,13] . This study used this perspective to analyze how discourse markers in gender-based humors served as barriers for gender mainstreaming. Gender mainstreaming has simple objective, i.e., it …transforms society positively through the elimination of discriminatory laws, norms and practices [14] . Prejudiced norm theory suggests that the use of disparaging humor creates a social atmosphere that supports and encourages prejudice and discrimination through transgression of established boundaries of social acceptability [5] . It could be that gender mainstreaming is challenging to achieve online because of language use and reiteration of social norms in social media. The presence of humor in communication had a notable impact on reducing the perception of sexist attributes associated with the conveyed message, while humors also heightened level of tolerance towards instances of sexual misconduct and sexism [15] . This study was an extension of the research conducted by the authors about discourse markers and message patterns of gender-based humors in social media. The initial results indicated that "perceived inequality was firm to the language and expression of the gender-based humor" [6] . This study extended the previous study conducted on gender-based humors in social media. It is believed that how gender-based humors being reiterated in social media has implications on how people react on gender mainstreaming campaigns. GAD is an essential concept to be discussed in sociolinguistic perspective. This study looked on how linguistic dynamics became a barrier in achieving gender sensitivity initiatives. --- Theoretical framework This study used the theoretical perspectives of Prejudiced Norm Theory and Cultivation Theory in developing the concepts of this study. --- Prejudiced norm theory Utilization of disparaging sexist humor has the potential to facilitate the manifestation of unfavorable attitudes and the acceptance of violence directed towards women. In the realm of social psychology, Ford and Ferguson [5] put forth the Prejudiced Norm Theory , wherein they posit that the utilization of disparaging humor fosters an environment conducive for prejudice and discrimination. This is achieved by pushing the boundaries of what is deemed socially acceptable, thereby providing an avenue for individuals or groups to openly exhibit their biases towards those who are different from them . In the context of sexist humor, it is observed that such humor establishes a social norm characterized by levity, thereby implying the potential acceptability of discrimination and the endorsement of acts of violence targeting women [16,17] . As Ford and Ferguson [5] clarified in their overview of PNT, "…humorous communication activates a conversational rule of levity-to switch from the usual serious mindset to a nonserious humor mindset for interpreting the message. Therefore, people are likely to interpret disparagement humor in a nonserious, humor mindset unless internal or external cues suggest that it is inappropriate to do so". Moreover, the study conducted by Woodzicka et al. [18] revealed that the lack of confrontation towards sexist humor can be attributed to its perceived lesser severity when compared to other forms of discriminatory messages conveyed through humor. Racist statements were found to be perceived as more offensive and confrontational when compared to sexist messages [16,17] . In their study, Mallett et al. [15] discovered that humor has the effect of diminishing the perception of sexist attributes associated with the communicated message. This outcome leads to increased acceptance of the message, reduced confrontational responses, and heightened tolerance towards displays of sexual harassment and sexism. The phenomenon of ingroup identification plays a significant role in moderating the perceived humor of jokes. The argument is supported by several studies conducted recently [16,17,[19][20][21]. Individuals who exhibited a diminished sense of identification with their ingroup were found to have a greater likelihood for gaining enjoyment from engaging in disparaging humor targeting the said ingroup. According to Abrams and Bippus [22] , research conducted in the field of sexist humor studies has revealed an interesting phenomenon. Specifically, women who exhibit a strong identification with their gender are more susceptible to the negative effects of critical messages directed towards them, as compared to women who have a lower gender identification [16] . This phenomenon suggests that individuals tend to exhibit ingroup biases, leading them to prefer humor that belittles the outgroup to a greater degree. --- Cultivation theory A few studies looked at how the controversy stoked long-growing concerns about social media's potential to affect audiences' perceptions and conduct instantly and directly. Traditional media still has a significant impact, but social media may have an even greater impact [23][24][25][26][27][28] . The concept of cultivation theory posits that the portrayal of a particular subject matter in the media can exert a significant influence on individuals, leading them to perceive the issue as more prevalent and representative of the actual world at large. This theory recognizes the dynamic nature of media's impact, as it has the potential to shape and cultivate viewers' perceptions and beliefs about various societal concerns [27,29- 32] . In cultivation studies, children who engage in extensive television viewing may internalize the notion that boys are inherently inclined towards exhibiting characteristics of dominance, assertiveness, and power. This phenomenon can be attributed to the frequent portrayal of male characters embodying such qualities on screen [33] . As Gerbner et al. [34] explained, "…Most of those with certain social and psychological characteristics, dispositions, and world views-and fewer alternatives as attractive and compelling as television-use it as their major vehicle of cultural participation. The content shapes and promotes their continued attention. To the extent that television dominates their sources of information, continued exposure to its messages is likely to reiterate, confirm, and nourish their values and perspectives". Most of the literature in cultivation theory were adapted more on mainstream media e.g., films, television, and this study is one of the few that integrated cultivation theory in social media, especially in the context of gender-based humor. In cultivation theory, the construction of the value system, which encompasses ideologies, assumptions, beliefs, images, and perspectives, is largely influenced by television [35] . In the concept of genderbased humor, social media posts could influence how people perceive gender stereotypes. Cultivation is the process of socialization involves various agents through which individuals acquire knowledge and internalize societal norms. In this context, media, including various forms of mass communication, play a significant role in shaping adolescents' understanding of gender norms within society [36,37] . From a media psychological standpoint, this shows that certain characteristics of social media could facilitate cultivation processes comparable to those identified in the historical setting of mainstream media [38] . --- Research objective The goal of this study was to determine the effects of discourse markers and message patterns of online gender-based humors to gender mainstreaming. This study collected narratives on what aspects the genderbased humor exert significant impact on gender mainstreaming. Discourse markers of gender-based humors include normalization of gender inequality, tolerating sexist jokes, and promotion of discrimination towards gender. These aspects might have social implications in gender mainstreaming. 1) Assess the effects of the dominant discourse markers and the message patterns of online gender-based humors to the mainstreaming campaign of gender and development. 2) Determine what aspects of gender-based humors made gender mainstreaming challenging to achieve. --- Methods This study explored the effects of gender-based humors in gender mainstreaming campaign. This study developed in-depth analysis on how gender-based humors in social media could impact the gender mainstreaming campaign through analyzing the narratives of social media users and language teachers. This study analyzed the discourses present in social media and extract valuable insights on how its message delimits the gender mainstreaming campaigns. --- Population and sampling technique The sampling technique employed in this study was purposive sampling, a non-probability sampling method commonly used in qualitative research [39][40][41] . This method involves selecting participants based on specific criteria that align with the research objectives, allowing for a targeted and purposeful selection process [42] . It is utilized by researchers to deliberately identify and select individuals who possess the necessary knowledge and expertise to provide valuable insights and information pertaining to the specific topic being investigated. The individuals included in the sample for this research study were specifically identified as active users of social media platforms, spending a minimum of four hours per day to online engagement. The participants in this study exhibited diverse gender orientations and profiles, which allowed for a comprehensive exploration of the various sources of humor expressions found online. This study used several characteristics, e.g., persons in authority, GAD advocates, language teachers. These were the main criteria this study used to describe the demographics of the participants. There were 14 participants in this study as presented in Table 1. They spend at least 4 h a day in social media. They actively engage in social media through messages, sharing, commenting, and posting. The basic profile of the participants is presented below. --- Research instrument The instrument in this study was the guide questions based on the objectives. This study carried out focus group discussions to gather the narratives from the participants. Below table present the research instrument used in this study. Focus group discussions on dominant effects of discourse markers: To determine the effects of the dominant discourse markers and the message patterns of online gender-based humors to the mainstreaming campaign of gender and development . The interview guide questions are presented in the Table 2 below. --- Data gathering procedure To collect data for the study, a rigorous data gathering procedure was employed, encompassing both focus group discussions and individual interviews. The focus group discussions were conducted with a group of participants who were purposefully selected based on their experiences pertaining to the subject matter under investigation. The discussions were organized in a structured manner, which fostered the opportunity for openended inquiries and facilitated dynamic exchanges among the participants. The recorded sessions were carefully transcribed to accurately capture the intricate details and subtleties of the conversations. The FGD offered valuable opportunity to explore and gain a more comprehensive understanding of the unique experiences and perspectives of each participant. The FGD was conducted with the consent of the participants, following ethical standards throughout the research process. The focus group discussion was conducted in a conducive setting that was convenient to the participants and allowed them to openly express their experiences. The researcher diligently upheld a neutral position during the entirety of the data collection procedure, displaying an unwavering commitment to impartiality. This was achieved by engaging in active listening and employing probing techniques to elicit additional information whenever deemed necessary. --- Data analysis The primary data in this study was the narratives from focus group discussion. The transcriptions were reviewed and coded to identify key themes and narrative patterns. Thematic analysis was used to systematically analyze the data and identify common ideas and responses. The findings were compared to other responses. In thematic analysis, there were six important components that needed to be followed-familiarization, coding, generating themes, reviewing themes, defining themes, and writing [43] . In this study, the responses of the participants were grouped based on their common themes and interpreted narratively. This further simplified complexities in their statements and expressions. This study also collected data from social media sites to triangulate the narratives with some gender-based humors. Because this study presented language use and effects, it is important to also present some examples of gender-based humors in social media. This allowed extraction of valuable language use ethics and standards. --- Results Objective 1. Assess the effects of the dominant discourse markers and the message patterns of online gender-based humors to the mainstreaming campaign of gender and development. Theme 1: Gender stereotyping in career development Four of the participants in focus group pointed out their concerns on how gender-based humors in social media can affect how people view career development. Some participants cited examples like being president or pilot. These gender-based humors in social media can impact how most people perceive careers. In that sense, they believe that humors can direct someone to normalize gender stereotypes of some works. "It is very evident that we are still not able to achieve equality. Even in academe, there is inequality because we are not able to tackle gender stereotyping and gender biases. For example, you are a woman, you cannot be a president of the university, why not?" [Participant 2] "It is necessary to intensify the gender mainstreaming especially in courses that gender stereotyping is prevalent." [Participant 12] "People believed that if a gay will lead the country, it will be a great failure for the country. These are some of the tolerating sexist jokes." [Participant 3] Theme 2: Self-perception Five of the participants in focus group believe that gender-based humors can influence self-perception of a person. This was an important direction for analysis because GAD is also focusing on empowering people within communities. It turns out that gender-based humors severely impacted how people perceived themselves. Some participants said that these humors are traumatic and causing people to self-isolate. "Psychological effects of dominant discourse markers, like short-term. This could include the perception to oneself, you'll lose confidence to yourself. When these jokes are pertaining to you, you'll lose your confidence as a person." [Participant 14] "In short term, you'll be angry. It has a domino effect because people will believe even if it is not true. In that case, when you react on these jokes, people will keep on doing it." [Participant 8] "It is traumatic to the person; it can affect how people perceive themselves. It has a social effect on them, and that they are less likely to socialize. They isolate themselves." [Participant 4] Theme 3: Social characterization Five of the participants in focus group pointed out how gender-based humors caused social characterization. People in social media developed words that described people as a joke. Because humors in social media is a dynamic culture, it often resulted to new descriptions to people. These descriptions are being used oftentimes to make fun of someone on the internet. These words have specific connotations to them which people continuously used. --- "The humors have characterization. People tend to look at these people and create certain ideas related to them. They will give them attribution to something, say, Marites [name called for a gossiper]." [Participant 1] "I think that why humor become trending because people can relate to it. For example, it's not wrong being gay, so why you will be offended? We tend to create image to ourselves about certain gender, we stereotype them as this." [Participant 5] "When we see males joining with girls, we always perceive them as gay. Even if they are masculine, if a male is joining with girls, he is gay. When a girl, we perceive her as tomboy [lesbian]." [Participant 7] "For me, jokes really exist, it's normal. We use Karen [racist] or Marites [gossiper]. There is also new now, Raul, a name used to bully a gay [often spoken with deep male voice]. So, if we don't know the meaning of these words, do not use it. Or might as well, don't use it even we know." [Participant 9] Objective 2. Determine what aspects of gender-based humors made gender mainstreaming challenging to achieve. Theme 1: Humor culture Some of the participant explained important contexts of gender-based humors in social media. One participant argued that it is difficult to understand humors because people differed their perceptions about it. He also emphasized that this is an important concern because it certainly contextualized how gender-based humors are developed. --- "Discrimination in social media may not be tangible enough to be understood by us. How many people are being caught because of cyberbullying? Like how liable the person is when he jokes? Some will view it as a joke, and some will not. That is the time humors have ethical dilemma because it is not clear what are the possible actions that a person should follow." [Participant 10] "I think, how people act in social media based on what they hear, read, or see. So, when a person is frequently exposed in gender-based humor, it makes them believe that it's normal, and that they can also do that." [Participant 6] Theme 2: Humor Dynamics Three of the participants expressed their concerns on how gender-based humor is evolving throughout time. The humors in social media are dynamic language that has its own syntax and linguistic components. Some people used humors as a form of insult, and this happens even with gender-based humors. These aspects of gender-based humors complicate more how gender mainstreaming can be implemented. --- "If they see these humors as normal, oh it's normal to joke like this, it has discriminatory undertone. So, the meaning changes. The humors in social media evolve, there are explicitly offensive becoming implicitly offensive because you don't know the context-someone is insulting you. So, if we don't stop this, if we just allow this to happen, it will really delay the success of GAD." [Participant 11] "If we allow this to happen all the time or occasionally, it will really hamper mainstream success. Whether it's small, incidental, and you let it be, tolerate it anyway they are humans, it will breed, it will connect-connect and will cultivate a culture that is tolerant like it's okay." [Participant 13] --- Discussion Objective 1. Assess the effects of the dominant discourse markers and the message patterns of online gender-based humors to the mainstreaming campaign of gender and development. This study yielded important effects of gender-based humors to the gender mainstreaming. These effects had several characteristics that needed to be investigate further to develop strategic processes. The narratives of the participants opened new discussions on which aspects gender-based humors became prominent and how these can potentially impact the gender campaigns within the community. For instance, one participant said that "we are still not able to achieve equality" [Participant 2] expressing concerns on how prevalent discriminatory speech and language use in social media are. Genderbased humors became a channel to explicitly express stereotypes because people perceived it as "normal." Notably, gender-based humors are form of statements that aim to entertain people, but some used it to spread discriminatory statements. This study presents Table 3 with some of the gender-based humors that are collected from social media feeds. --- Posts Expression So you're a female doctor? Females are not fit of being a doctor. Women's world cup??? Ain't nobody got time for that. Women should not participate in sports. --- Table 3. . --- Posts Expression They say a women's work is never done. Maybe that's why they get paid less… Women are not commitment to their words and deserve to receive low wages. Gender is a social construct. I was born a transgender. Gender orientation is a choice. Assessing the effects of gender-based humors was broad process. However, the narratives from the participants shed light on different angles to be investigated e.g., career development, personal and selfperception, and social characterization. These aspects appeared to be prominent effects that might delimit people to support gender mainstreaming within communities. Although gender mainstreaming has been in the system of policy development across the world, there was limited assessment done on how it can be implemented in social media. One main barrier of gender mainstreaming is patriarchy. As Cameron [44] argued, "patriarchal social relations remain deeply embedded in almost all societies" and explained language can be "an instrument of male power over women, used to silence, misrepresent, belittle, and harass." In case of media, it appears that informative, entertainment, and promotional content is becoming more sexualized, making it harder to achieve gender equity on a daily basis [45] . In a small-scale study of Anggraheni et al. [46] , 22% of women experienced hate speech in social media. At a conversational level, individuals employ gender cues as a determining factor in shaping their behavioral responses towards others during social interactions [47] . Humorous communication is crucial in the establishment of normativity and normality [48] . Naturally, humor changes norms by breaking them and promoting new perspectives [49] . Bergmann [50] posited that tendentious jokes are dangerous because they perpetuate and amplify existing stereotypes "for fun" without allowing them to be seriously rethought. It is important to acknowledge the power imbalances and structural inequities prevalent in the society when considering the impact of ethnic jokes [51,52] . These jokes are not only harmful but also have the potential to create divisions within social dynamics. Specifically, individuals who do not find such jokes entertaining may be perceived as outsiders, further exacerbating the existing social disparities [51] . This explains why genderbased humor in current days become barrier for gender mainstreaming because "…they will give them attribution to something" [Participant 1] and "it can affect how people perceive themselves" [Participant 4]. Psychological research in sexist humor, which encompasses humor that perpetuates stereotypes and demeans individuals based on their sex or gender, substantiates the viewpoints of those who associate humors with adverse social consequences [53,54] . Sexist humors yield consequences on individuals' perceptions of others, specifically with regards to their gender, as well as their likelihood to engage in discriminatory behaviors [51,54] . Therefore, it can be inferred that the impact of sexist humor can significantly influence the self-perception of the targeted demographic within the specific social context in which the humor is generated [51] . In this study, intensity of gender-based humor in social media might hamper the gender mainstreaming. For instance, it has been determined that normalization of gender-based humors often results to reproduction of this behavior. As one participant said, "…humor become trending because people can relate to it" [Participant 5]. It turns out, gender-based humors were simple form of statements that become relatable to others. Oftentimes, this mechanism engaged people to develop humor-encompassing behaviors. This note aligns with previous research [51][52][53] that has demonstrated the adverse consequences of employing disparaging humor, which contributes to the development and normalization of inequitable social dynamics. The challenge of addressing problematic and stereotyping humor, whether it is propagated through institutionally like songbooks, in social spaces such as student-run bars, or in everyday interactions like classrooms, poses significant barrier for equity initiatives [51] . In social media, stereotyping humor is severely normalized because of in-group shared culture. For instance, group contexts have the potential to cultivate a psychological phenomenon known as a "us versus them" mentality, thereby promoting a sense of bonding among individuals within the group [55,56] ; men form bonds with other members of their group by participating in sexual misconduct against woman if group norms accept it [21,56,57] . There were several examples on how people use gender-based humors to characterize someone. One humor explains "…when we see males joining with girls, we always perceive them as gay" [Participant 7], certainly, "when you react on these jokes, people will keep on doing it" [Participant 8]. This social complexity further highlighted the challenge on how to manage gender-based humors in social media. Gender-based humors oftentimes gather people with common norms. It became challenging because people share norms which enabled them to be explicitly discriminatory. Gender-based humor in online spaces can have significant effects on gender mainstreaming campaigns and perpetuate discriminatory attitudes and stereotypes. The normalization of gender-based humor can contribute to the reproduction of discriminatory behaviors and hinder efforts towards achieving gender equity. The challenge lies in addressing problematic and stereotyping humor, as it is often normalized in social media and shared within in-group cultures, reinforcing discriminatory norms. Managing gender-based humor in social media poses a complex challenge in promoting gender mainstreaming and addressing inequitable social dynamics. Objective 2. Determine what aspects of gender-based humors made gender mainstreaming challenging to achieve. This study had important narratives on how gender-based humors made it challenging to achieve gender mainstreaming in social media. It was indicated that gender-based humors, in essence, have specific thematic mechanism that enable people to distribute and expand people's norm. This is an important discourse because it showed how challenging it can be to extend gender mainstreaming in social media because of its saturated gender stereotyping potentials. One participant said that "…discrimination in social media may be not tangible enough to be understood by us" [Participant 10]. Although this does not mean that gender discrimination should be normalized, it points out how challenging gender mainstreaming to be achieved. Notably, Participant 10 was concerned about the complexity of gender-based humor culture in social media that delimits the mainstreaming campaign. Humor culture in social media has detrimental effects on mainstreaming efforts. Aside from its capacity to recreate humors that present discriminatory behaviors, humor culture cause people to tolerate humors and accept them as part of normal conversations. This has major implications on how to deliver mainstreaming campaigns because when people accept something as norm, even with policies, people would deliberately break these policies. Gender-based humors made it challenging for gender mainstreaming to be adopted in social media. For instance, one comment in Table 4 said that "it is very difficult to be discriminated… because what they say is true" indicated discrimination cultivates acceptance of gender normativity. Social media has the potential to magnify stereotypical portrayals of individuals living in poverty, consequently diminishing their prospects in terms of economic and educational advancement. The practice of categorizing individuals into distinct groups, namely the 'deserving' and 'undeserving' involves evaluating their proficiency in the domain of online impression management. Similarly, gender-based humors also magnify normative expressions e.g., gays are weak, women are dependent to men, because people in social media used generalized expressions to share group stereotypes. Word use, like "facts," reinforce the information about gender, while the use of strategic generalization stresses a humor generally applies to people in certain group [64] . This is challenging for gender mainstreaming to be achieved because language use is a powerful tool in reiterating gender stereotypes. Online spaces are known to be an effective grounds of gender stereotypes. Media content is highly suitable for facilitating social learning processes due to its characteristic inclusion of simplistic and frequently onedimensional models of rules and behaviors that are frequently seen [58,59] . This has been shown in televisions and media contents whereby exposure to television content elicits the activation of associated schemas. In cultivation theory, this process of activation leads to the reinforcement and increased accessibility of specific schemas or cognitive frameworks, thus impacting an individual's perception and interpretation of the world [59] . This explains why "[gender-based humors] will cultivate a culture that is tolerant like it's okay" [Participant 13]. In this study, several mechanisms of gender-based humors emerged as channel for discrimination and stereotyping. For instance, one participant said that "…if they see these humors as normal… it has discriminatory undertone" [Participant 11]. This indicates that while gender-based humors remain normalized, it cultivates behaviors that reinforce gender stereotypes. This note was aligning with previous studies in gender stereotyping and discrimination in social media. As Lomotey [60] concluded, humors "…camouflaged and discreetly perpetuated negative stereotypes and ideologies about gender and were therefore morally objectionable". Philosophically, people do not only hear jokes but also reiterate them [61] . Memes emerge during instances of challenging prevailing narratives. Through their participatory nature of recreation and mutations, memes facilitate the resolution of ideological conflicts and the reestablishment of a normative narrative [62][63][64] . The language used in gender-based humors has implications to gender mainstreaming. Sexist jokes reinforce the existing patriarchal structure within societies, thereby perpetuating the unequal power dynamics favoring men over women [65,66] . Language become a tool to infer gender stereotypes and mobilize power dynamics. The role of language in the context of humor lies in its responsibility for accurate articulation of the joke and the subsequent delivery of the punch line [67] . Women are commonly portrayed in material reality as "the second sex" [68] , and that language is meant to maintain gender distinctions [66] . This demonstrates why "…there are explicitly offensive [humors] becoming implicitly offensive because you don't know the contextsomeone is insulting you" [Participant 11]. Humors in social media change because of dynamic language use which cultivates gender normativity. Message patterns and discourse markers were significant mechanisms of language use in humors because it presents discriminatory undertone. The cultivation theory explains how exposure to gender-based humors reinforces specific cognitive frameworks and impacts individuals' perception and interpretation of the world, thus contributing to the acceptance of gender-based humor as the norm. Normalization cultivates behaviors that reinforce gender stereotypes and discrimination. Language plays a crucial role in gender-based humor, as sexist jokes and language perpetuate unequal power dynamics favoring men and maintain gender distinctions. The use of strategic generalization and discourse markers in humor language reinforces gender norms and presents discriminatory undertones. Gender-based humor in social media hinders the achievement of gender mainstreaming by perpetuating stereotypes, normalizing discrimination, and mobilizing power dynamics through strategic language use. --- Conclusion The study highlights several aspects that contribute to these challenges. Firstly, gender-based humor has a thematic mechanism that allows for the distribution and expansion of gender norms, making it difficult to extend gender mainstreaming efforts. The complexity of gender-based humor culture in social media limits the effectiveness of mainstreaming campaigns. Gender-based humor hampers gender mainstreaming by perpetuating stereotypes, normalizing discrimination, and mobilizing power dynamics through language use. The study emphasizes the need to address these aspects in order to promote gender equality and create an environment that is more inclusive and supportive of gender mainstreaming initiatives. The use of humor reinforces the reproduction of discriminatory attitudes and stereotypes, which can hinder efforts towards achieving gender mainstreaming efforts. Managing and addressing stereotyping humor in social media poses a complex challenge in addressing inequitable social dynamics. In-group cultures further reinforce discriminatory norms, making it difficult to address and manage gender-based humor effectively. However, although this study indicated how language use can influence reiteration of gender stereotypes and discriminatory messages through humors, there is a need to determine how do language teaching neutralizes the mechanisms of social norms and its cultivation in social media. --- ---

Cultivation of gender-based humor in social media encourages contrarian language to gender mainstreaming. Gender-based humor posed threat on how to deliver equitable gender mainstreaming campaigns through online. The goal of this study was to determine how gender-based humor impact gender mainstreaming campaign in sociolinguistic sense. There were 14 participants in the focus group discussion providing collective narratives on proliferation of gender-based humors in social media. The participants were language teachers, Gender and Development (GAD) coordinators, and GAD advocates. Discourse analysis indicated that language use in social media hampers the delivery of gender mainstreaming campaigns. Social characterization and social distinctions were prominent components of the humor language, which then cultivated gender normativity. Gender-based humor perpetuate stereotypes, promote discriminatory practices, and reinforce power imbalances through linguistic means. In larger scale, humor language influences the reproduction of humor culture in social media. Gender mainstreaming slows down because of massive cultivation of social belief systems. The problem lies on how gender stereotypes are normalized in society through language use.

Introduction Stroke, an acute-onset cerebrovascular disease, is one of the most critical public health problems worldwide. The World Health Organization reported that 15 million people worldwide are diagnosed with stroke yearly, of whom 500 die and another 5 million are permanently disabled. 1 In China, stroke incidence has been reported to increase by an average of 8.3% per year 2 and the Global Burden of Disease 2019 study results showed that China has the highest incidence of stroke at >30%. 3 One study estimated that the number of stroke survivors could increase to 31.7 million by 2030. 4 A total of 75% of stroke survivors are incapacitated, while 40% are severely disabled, 5 adversely impacting their quality of life. However, some survivors and their families can recover from adversities, gain new advantages and utilise social resources in times of such challenges. 6 Walsh et al 7 argued that a high level of household resilience helps families withstand the challenges that the disease brings. Family resilience refers to using resources, such as individuals, families and communities, to support recovery from adverse events, achieve positive outcomes and facilitate good family adaptation. 8 In China, the stroke pathway involves a complex interplay of factors influenced by the healthcare system, cultural norms and socioeconomic conditions. China faces unique challenges in managing strokes due to the sheer magnitude of stroke cases and the evolving healthcare infrastructure. Unlike other developed countries, the level of medical services in China's grassroots communities is still in its infancy. As a result, approximately 80% of patients prefer home care. 9 Owing to the acute onset of stroke, some patients become permanently disabled, which allows caregivers to adapt to their unexpected roles as carers with little preparation. 10 In addition, many family caregivers face significant problems, such as financial constraints, inadequate rehabilitation knowledge and overburdening. 11 The transition from hospital to home is considered the most challenging period for stroke survivors and their families since they must adapt to the distress that the disease brings. 12 At present, family resilience has been studied in several chronic disease groups, such as the families of patients with cancer and those with acquired immunodeficiency syndrome, although it is rarely applied in the families of stroke survivors in China. 13 Family resilience is the starting point and may be an intervention target to promote the adaptation of patients in China after a stroke. However, research on family resilience is limited. [14][15][16] Unfortunately, they did not identify a specific period that impacted family resilience. Therefore, the purpose of this study was threefold: to gain a preliminary understanding of the level of family resilience of stroke survivors in China, to explore the factors influencing the family resilience of stroke survivors in China and identify the favorable factors and risk factors and to establish effective coping strategies for patients' family members and provide a theoretical basis for strengthening their coping abilities. --- Methods --- Study Design The study was conducted at a tertiary hospital in central China. The researchers used a sequential explanatory mixedmethod approach 17 to expand and strengthen the understanding of the family resilience of stroke survivors in China. This approach comprised two main components: a questionnaire and interviews. The first stage of this study involved a quantitative research methodology; this was used to understand the status of the family resilience of stroke survivors, explore the correlation between family resilience and self-efficacy in disease management, caregiver burden, family function and social support and analyse the factors influencing the family resilience of stroke survivors in China. To select representative patient families for interviews purposefully, the second stage of this study adopted a qualitative research methodology . A semistructured interview framework analysed and mined critical themes, clarified the factors that act as obstacles in building family resilience of stroke survivors and explored possible favorable factors. --- --- Data Analysis Quantitative Research In the quantitative research stage, social support was measured using a general demographic sociological data questionnaire, the Family Resilience Assessment Scale , the Self-Efficacy for Managing Chronic Disease 6-Item Scale to measure self-efficacy in disease management, the Caregiver Burden Scale to assess caregiver burden, the Family Functioning Scale to evaluate the family function and the Social Support Rating Scale. The quantitative data collection process was as follows: The questionnaire was distributed by the researcher to the families of patients who had suffered a stroke who met the inclusion criteria in the outpatient ward of the Department of Neurology of a tertiary-level hospital in a province in China. Before the survey, the researcher established a good relationship of trust with the patients and their family caregivers, informing them of the purpose, methodology and content of this study and voluntarily filling out an informed consent form, informing them that this questionnaire was limited to this study and would not disclose their privacy. The self-efficacy questionnaire was completed by the patients themselves, or the researcher read the questions and the patients answered them and then the researcher completed them on their behalf. The other questionnaires were completed by the primary family caregiver on behalf of the family. After the questionnaires were completed, the researcher checked the questionnaires for completeness, and if there were any incorrectly filled or omitted options, they were corrected and verified on the spot with the study participants and the patients were thanked. The survey data were analysed using IBM SPSS 26.0 software. Sociodemographic data and participants' characteristics were summarised using descriptive statistics . An independent-sample t-test or a one-way analysis of variance was used to analyse the differences in family resilience between different sociodemographic data, and p < 0.05 was considered statistically significant. In addition, Spearman correlation analysis was used to analyse the correlation between the self-efficacy of disease management, caregiver burden, family function, social support and family resilience. Finally, the variables with p < 0.05 in the univariate analysis were taken as independent variables, and the total family resilience score was taken as a dependent variable. A multiple linear regression analysis was performed using a stepwise method, with the family resilience level as the dependent variable and statistically significant variables from the univariate analysis as independent variables, to clarify further the effect of each influencing factor on the family resilience of stroke survivors. --- Qualitative Research A phenomenological approach was adopted to delve into the lived experiences of stroke survivors and their families. This approach was chosen for its suitability in uncovering the essence of these experiences, allowing for an in-depth understanding of the phenomenon under investigation. The recruitment process involved selecting patient families that were representative of the current status of different family resilience levels. A representative sample was selected with due consideration of family resilience score, age, family situation, place of residence, different stages of the disease, degree of illness, caregiver's literacy level and caregiver's work status. The interviews were conducted by two researchers, one of whom was responsible for conducting the interviews, while the other, with the consent of the interviewees, synchronised the audio recording of the interviews, while recording the interviewees' reactions and expressions objectively. During the interviews, the researchers tried to avoid inducing the interviewees with their subjective opinions. If there were any doubts about the content of the interviews, they would promptly repeat the interviews to the interviewees to confirm the accuracy of the information. Within 24 hours after each interview, the researcher listened to the interview recordings, read the on-site transcripts several times and organised the transcripts word by word and sentence by sentence into a word version of the information, with non-verbal information such as pauses, emotional reactions and body movements in parentheses in the corresponding positions, to ensure that the organised information maintained accuracy, authenticity and completeness. Colaizzi's seven-step analysis was used to analyse the interview data. Specifically, it included the following: recording in detail and carefully studying all interview materials, extracting meaningful statements that echoed the phenomenon of family resilience, extracting and summarising the meaning of valuable expressions, organising the extracted meanings into themes, theme groups and categories, linking the theme to a complete narrative of the research phenomenon, stating the essential structure, feeding the results of the resulting data analysis back to the interviewees to verify the accuracy of the content and, finally, gradually refining and sublimating the research themes through feedback from the research subjects, group discussions and expert confirmation. Thematic analysis was employed to identify patterns, themes and categories within the qualitative data. The process involved data familiarisation, generation of initial codes, searching for themes, reviewing themes, defining and naming themes and producing the final report. Reflexivity, though not explicitly mentioned, was integral to the process, with researchers acknowledging and critically reflecting on their assumptions, biases and preconceptions throughout the analysis. Social Support Score In this study, the scores of family social support of patients who had suffered a stroke ranged from 23 to 59 points, with an average score of points, among which the scores of objective support, subjective support and social support utilisation were points, points and points, respectively. The average scores of the three dimensions were ranked from low to high as utilisation of support, objective support and subjective support, among which 34.1% of families with patients were at the high level and 65.9% were at the medium level. The results showed that the level of family social support of patients who had suffered a stroke was generally at the medium level. --- Family Resilience Score The mean FRAS score was , which was above the medium level . The score of the family belief subscale was , and the score of the family strength subscale was . The mean score of each item of the family resilience of stroke survivors was >3.4. Among them, the degrees of family resilience of stroke survivors with different marital statuses, medical payment methods, stroke courses, caregiver's education levels and work situations differed. The difference was statistically significant , as shown in Table 3. For example, the families of divorced and widowed patients had lower levels of resilience than the families of married patients. The Spearman correlation analysis results showed that cerebral apoplexy and the faith and strength of patients' families were positively correlated with self-efficacy scores, disease symptom management efficiency, common disease management efficiency, social support, objective support, subjective support and the degree of support utilisation, but they were negatively correlated with family function and care burden . The multiple stepwise regression analysis results showed that eight variables entered the regression equation, and the researcher concluded that family function was the strongest influencing factor on family resilience . Other variables are shown in Table 5. --- Qualitative Results Theme 1: Loss of Independence and Certainty Subtheme 1: Loss of Independence Stroke impairment causes the loss of independence and normal activities of daily living; it directly impacts the daily lives of family members, particularly the loss of independence and autonomy and the ability of the primary caregiver to plan their daily work and life appropriately. Some of the participants' statements are reproduced below: S1: He suddenly became incapable of doing anything; his right arm couldn't be lifted, and eating and going to the bathroom were difficult. In order to take care of him, you do not have to do anything else yourself; you can only do that at home. S7: My son rarely travels on business, and sometimes, he won't go out for drinks or food with friends since his mother is ill. No way! I am older: I cannot handle her alone; my son can only come back early from work and give me a hand. S12: As soon as I graduated, I went straight to Shanghai to work. Now I have resigned from my job and returned to my hometown because my mother needs my help to take care of her father. --- Subtheme 2: Full of Uncertainty Patients who suffer strokes have no way of knowing whether the disease will recur or what life will be like once they leave hospital and return home. Some of the participants noted the following: S6: It is hard for me to go out in an emergency when my mother is home alone because I am scared that she may fall. S9: In the beginning, he recovered very well, and I could return to work normally. However, he suddenly developed epilepsy when he was doing rehabilitation exercises, and now he is walking worse than before. S14: Now whatever you plan is futile; just count the days, and don't ask for too much. Theme 2: Facing threats and challenges Subtheme 1: Heavy Economic Burden A long rehabilitation process and high medical expenses are associated with stroke, which places enormous financial pressure on families. Moreover, some family caregivers have to reduce their working hours or even leave their jobs to care for patients. The financial impact on the family was mentioned by some family caregivers. S9: My salary wasn't great, and now I have to change shifts or take time off to take care of him. When he was healthy, our family relied heavily on him to work so that the kids could attend school and support the family. But now that he is sick, if I absolutely need money, I borrow from friends and family. --- Subtheme 2: Post-Stroke Negative Emotions Most stroke survivors are left with sequelae, coupled with the uncertainty of stroke recurrence owing to the high disability rate of the disease. Patients experience negative emotions, such as anxiety, depression, stigma, anger and mood disorders. At the same time, heavy caring tasks also bring negative psychological experiences to family caregivers, such as anxiety, fear, depression, role strain and fatigue. Participants Expressed the Following S1: He has a strong personality. Although he has told us all his psychological words, I can feel his heart is still sad. Why should it happen to him? S10: Sometimes, while lying in bed at night, a person will often shed tears; I am often anxious and nervous, afraid that he will relapse. --- Subtheme 3: Heavy Care Burden The fatigue of long-term care work and the lack of professional care knowledge impose a heavy burden on family caregivers. Mental strain, reduced social interaction, physical fatigue, sleep disturbances and memory loss are common symptoms of family caregivers. Participants expressed the following: S3: I often get a little dizzy, a little overwhelmed, and I often have to take medication. S5: I often have dreams or insomnia at night. I can't sleep well. I have no energy during the day, and my memory is not as good as before. Theme 3: Utilising Family Resources Subtheme 1: Internal Family Support After the onset of the disease, families face unprecedented pressure; for instance, family members need to utilise their own resource advantages, including family members' personality traits, health status, education level, care ability and beliefs about illness, to help families adapt to the new changes. One participant said the following: S4: This happened to my mother all of a sudden. It's no use being sad for us as children. We should still be positive and optimistic. --- Subtheme 2: Relationships Within the Family This mainly refers to the quality of the relationships between family members or family caregivers and patients before onset. A family with a good relationship will naturally support each other in all aspects to help the family adapt to difficulties better and faster. One participant said the following: S1: We have always had a good relationship, and our son is very dutiful. He works very well, and he can't accept that this happened, but I am glad that he was able to speak up and not keep it to himself. --- Subtheme 3: Support from External Resources After a stroke, various forms of support from relatives, friends and community health services coupled with adequate social interaction can effectively improve the resilience level of families to a large extent. Participants expressed the following: S7: The community hospital near our house is very good. It has rehabilitation equipment, and the doctor is extremely professional. Every afternoon I push my wheelchair to take him to do rehabilitation. S8: I will not let him stay at home every day; every day I push him to the community below to see others play chess and cards; ah, to let him have more contact with the outside, people are happy. --- Theme 4: Adopting Coping Strategies Family coping is a gradual process in which families use existing family resources to continuously generate and develop new behaviours to strengthen their ability to adapt to stressful events. Family members must redefine their roles, adjust the division of labour and adapt to the new environment. Family caregivers turn to others for help, learning about nursing and rehabilitation, rebuilding their daily habits and changing their mindsets. Some of the participants expressed the following: S6: My husband used to only go to work and do nothing at home. Now I have to take care of my mother, so I can only change him to cook for the child every day. The child said that he did not like to eat what he did, and he did not want to do it, but there is no way, I do not know what good way. S9: Every day I go online to learn some simple movements and to help him do rehabilitation activities. Professional movements cannot be learned, as there is no one to teach; ah, I can only learn to do a little bit: better than no activity. Figure 1 shows the themes and subthemes extracted from qualitative content analysis. --- Discussion In this research, we found that the family resilience of stroke survivors was above the medium level and was correlated with positive family functioning. Other factors that influenced family resilience included adaption experience , uncertainty about the future, financial burdens and negative emotions. Family functioning was the most important component of family resilience. The requirement for adjusting to daily routines to care for the rehabilitation of a family member after a stroke demonstrates the presence of one of the qualities of family resilience in overcoming problems. 18 The quantitative results did not allow for the understanding of how families adapt to changed living conditions when dealing with an adverse situation, but our qualitative results generated information pertinent to some phenomena of interest in the Chinese context, and the quantitative findings support the discovered themes. The loss of independence felt by stroke survivors affects caregivers' independence, but filial piety and some family values may support family members in overcoming their negative experiences. A strong interpersonal relationship after a stroke is important for the well-being of both patients and family caregivers. The findings of other studies highlight areas to consider in promoting strong relationships between patients and family caregivers. Cohesion and a strong emotional connection between family members support them in facing and overcoming such challenges. In this study, most caregivers were spouses. A good marital status was a protective factor for family resilience, and the marital relationship was an important link to maintaining the harmony and stability of the family relationship. Spouses provide unconditional care, strong psychological comfort and motivation for patients. The subtheme of "relationships within family systems" in the qualitative research section seems to explain this phenomenon. However, studies have shown that around 54% of families of stroke survivors experience relationship problems, and nearly 38% of couples experience open conflict. 19 Without supportive intervention, relationship problems tend to increase after a stroke, deteriorating relationship quality over time. 20 To reduce or eliminate the negative emotions of patients and family caregivers, medical staff and community healthcare providers should promptly discover and inform them of self-regulation methods, such as mindfulness therapy, music therapy and diary writing. 21 Informal caregivers describe their post-stroke lives as having been "turned upside down". 22 Caring for stroke survivors frequently burdens unpaid informal family caregivers because of the rapidly progressive nature of the disability and the ongoing, frequent and unpredictable nature of stroke recovery. 23 Participants in qualitative studies described financial, psychological and care burden threats and challenges they faced in adjusting to illness stress, which was also confirmed in quantitative studies. Not only did the caregiver burden affect family resilience but family resilience was worse when medical care had to be paid for. Family caregivers regularly bear the substantial costs of stroke survivors for a long time, and in some cases, they even forego treatment because they cannot afford such expenditure, 24 which significantly increases the risk of delayed recovery and even stroke recurrence. This study found that multi-channel economic support can adjust the impact of diseases on families, which is similar to the research findings of Lopez-Espuela 25 and Kariyawasam, 26 among others. Therefore, it is necessary to advocate for government departments to continue to implement medical insurance policies for serious diseases, formulate corresponding healthcare policies and promote re-employment-related measures to address the financial burden and employment status of family caregivers. Studies have shown that while coping with disease, the effectiveness of the coping strategy is directly related to whether a patient's family can achieve a good level of resilience. Mobilising resources and adopting positive coping strategies can reduce the vulnerability of families to cope with stress and enhance their resilience. 27 At the individual level, patients should be encouraged to promptly perform self-psychological counselling, and family members should repeatedly encourage patients to enhance their sense of self-efficacy and self-worth. At the same time, family members, particularly caregivers, should be encouraged to perform timely self-regulation to maintain good physical and mental states. In addition, this study found that, similar to the research results of Lietz 28 and Weitzel et al, 29 strong and powerful social support was a protective factor for the family resilience of stroke survivors, involving community and other resources to help families cope with challenges, obtain information and access emotional/instrumental support. This study lays the groundwork for future research in understanding and enhancing family resilience among stroke survivors in China. Subsequent investigations could delve into developing targeted interventions addressing the identified challenges, such as financial burdens and negative emotions. Exploring the effectiveness of support systems, both internal and external, on family resilience would be valuable. Additionally, longitudinal studies tracking the evolution of coping strategies and their impact on family well-being over time could provide insights for intervention development. Further examination of the cultural nuances influencing family dynamics and resilience in the Chinese context would contribute to a comprehensive understanding. Overall, future research should aim to inform practical strategies and policies that enhance the adaptive capacity of families facing the complex repercussions of stroke. --- Limitations This study recognises certain limitations that warrant consideration. First, the Chinese version of the family resilience assessment tool may have contributed to participant fatigue and potentially impacted response accuracy, given the extended questionnaire and investigation events. While efforts were made to minimise these effects, future research should focus on refining the assessment tool and developing a specific scale tailored to the context of stroke survivors to enhance the efficiency and ethical robustness of data collection. Additionally, the cross-sectional survey in the initial phase introduces a potential bias, and long-term follow-up may have influenced participants' work experiences, particularly among nursing staff. Longitudinal studies are recommended to establish causal relationships between study variables. Moreover, future research should explore additional factors and identify family strengths, contributing to a more comprehensive understanding of family resilience in the context of stroke survivors. --- Conclusions This study used mixed methods to help healthcare workers better understand the adaptation process of the families of stroke survivors and the factors influencing family resilience, including dominant resources and risk factors. Among these, family function was found to be the strongest influencing factor. Eliminating risk factors from a patient's life is practically impossible, but increasing their ability to cope with and adapt to difficult conditions despite increased risk factors is very important. Therefore, we suggest that clinical personnel focus on family strengths and conduct family resilience-oriented interventions to facilitate the adaptation, recovery and growth of the family as a unit as well as its individual members in the process of stroke rehabilitation and to reduce the burden on caregivers. --- Ethics Participants provided written consent and were explicitly informed that anonymised responses may be published as part of the study findings. Participants retained the right to withdraw from the study at any time. Personal information and relevant data were anonymised and coded to ensure confidentiality and privacy. --- Results --- General Information About the Patients A total of 258 questionnaires were distributed, 242 of which were recovered, yielding a 93.8% successful recovery rate. Fourteen primary caregivers took part in Phase II of this study, with sample sizes determined by data saturation. Patients who responded to the questionnaire were predominantly male , married and the breadwinner of the family ; the predominant disease type was ischemic stroke , mean age 61.86 ± 8.76 years. Most family caregivers were women and were aged <59 years , mean age 53.62±7.49 years. Participants in the qualitative study were aged 30-68 years, and eight were the spouses of stroke survivors . The participant information for qualitative research is shown in Table 2. --- Quantitative results --- Disease Management Self-Efficacy Score The chronic disease management self-efficacy scale was used to evaluate the self-efficacy of patients who had suffered a stroke in this study. The total score ranges from 0 to 10 points; the total average was points, showing a medium-low level. The average score of disease symptom management efficacy was , and the average score of disease commonality management efficacy was . Among them, 24.7% were at a low level, 67.3% were at a medium level and 7.8% were at a high level. --- Family Caregiver Burden Score The family caregiver burden score was , in which the personal burden score was and the responsibility burden score was . The burden of family care for patients who had suffered a stroke accounted for 32.0% at the severe level, 47.5% at the moderate level and 26.5% at the no-or mild-burden level, indicating that most of the caregiver burden in the families of patients in this study was at the moderate level. --- Disclosure The authors declare no potential competing interests.

Background: Stroke is a critical public health issue in China that necessitates a closer examination of family resilience (defined here as the collective capacity of individuals, families and communities to effectively navigate challenges, recover from adverse events and foster positive adaptation). Amid rising stroke incidence, this study addresses the dearth of research on family resilience among stroke survivors in China, aiming to assess its level, identify influencing factors and establish coping strategies for family caregivers. Methods: This mixed-methods research employed a sequential explanatory design. Questionnaires were distributed to 258 stroke survivors and their family members at outpatient follow-up visits. In the first stage (ie the quantitative research stage), the research tools for data collection included a general demographic sociological data questionnaire, the Family Resilience Assessment Scale (FRAS), the Self-Efficacy for Managing Chronic Disease 6-Item Scale, the Caregiver Burden Scale, the Family Functioning Scale and the Social Support Rating Scale. Quantitative data were analysed using IBM SPSS 26.0 software, utilising descriptive statistics for summarising sociodemographic characteristics and conducting analyses, such as independent-sample t-tests, one-way analysis of variance and Spearman correlation analysis. The second stage (ie the qualitative research stage) involved complementing and validating the data, developing a quantitative-qualitative interview framework and selecting participants for interviews. Colaizzi's seven-step analysis was applied to analyse interview data. In the third stage, the quantitative and qualitative research results were integrated, and a comprehensive analysis was performed to obtain an accurate conclusion. Results: A total of 242 families responded to the questionnaire (response rate: 93.8%). In total, the mean age of stroke survivors was 61.86 ± 8.76 years old, and 69.8% were male. The quantitative results showed that the FRAS mean score was (185.33 ± 24.78), which was above the medium level. The multiple linear regression analysis confirmed that family function was the strongest influencing factor on family resilience (β = 0.948, p < 0.01). The qualitative analysis revealed four themes of family adaptation experience: loss of independence and certainty, facing threats and challenges, seeking family advantage resources and adopting coping strategies.This hybrid study sheds light on the adaptation process of the families of stroke survivors, revealing family function as the primary influencer of resilience. Recognising that eliminating risk factors is challenging, our suggestion is for clinical practitioners to emphasise family strengths and implement resilience-oriented interventions. Focusing on enhancing coping abilities and fostering adaptation within families can aid in the rehabilitation process, promoting the well-being and growth of both the family unit and individual members, while alleviating caregiver burden.

INTRODUCTION Depression and anxiety have become major mental health concerns in low-income, middle-income and high-income countries, and their lifetime risk has been increasing steadily over the past few decades. 1 2 Depression has been projected to be the first cause of burden of disease by 2030 globally and has become a leading cause of suicides in China. 1 Previous evidence indicated that women were more likely to have higher incidence of depression and anxiety than men, and that there was a modest peak in prevalence in the fifth and sixth decades of life in both genders. 1 3-5 It has been estimated that 26.0% and 12.6% of Chinese women aged 40-60 years suffer from depressive and anxiety disorders, respectively. 6 Depression and anxiety are associated with functional impairment, reduced quality of life, and increased likelihood of cardiovascular risk factors and mortality. With the increase in ageing population and social transitions, China is set to --- STRENGTHS AND LIMITATIONS OF THIS STUDY Open access experience more severe health burden caused by depression and anxiety, particularly among middle-aged and older Chinese women. Hypertension has been considered a main risk factor for cardiovascular disease and premature deaths globally, and its prevalence has been increasing over the past decades. 7 In 2018, the National Chronic Disease and Risk Factor Surveillance conducted in 298 counties/districts in China reported that the prevalence of hypertension in Chinese adults was 27.5%, 30.8% in men and 24.2% in women. 8 A body of evidence indicated a link between hypertension and depressive and anxiety disorders. A previous meta-analysis including six studies reported a positive association between depression and hypertension in elderly populations. 9 Previous studies also reported that individuals with hypertension were more likely to experience depressive disorders, 10 11 while depressive disorders were correlated with increased odds of hypertension in middle-aged and older adults. 12 13 Different socioeconomic status leads to different degrees of social, cultural, political and economic conditions among populations, which may then affect health outcomes. Education and income are widely used as generic indicators of SES in epidemiological studies, since education is considered to reflect the knowledgerelated assets of individuals, while income is thought to estimate material resources and affordable healthcare. 14 Urban-rural residency is another important indicator of SES in China, as rural and urban areas have considerable disparity in lifestyle, environment, occupation and social structure, economic level, and healthcare delivery. 15 16 Previous evidence showed that low SES was associated with higher prevalence of depression and anxiety and worse prognosis outcomes. [17][18][19] Further, a previous meta-analysis suggested that low SES was linked with hypertension, and this relationship was especially evident in different levels of education. 20 However, little is known whether the relationship between hypertension and the risk of depressive and anxiety disorders may be affected by SES. This study, therefore, aimed to investigate the association of hypertension with depressive and anxiety disorders in middle-aged and older Chinese women, and to further assess whether the association was influenced by SES. --- METHODS --- Study design and participants This cross-sectional, community-based study of women was carried out in six provinces of three socioeconomic regions of China: western , central and eastern . The capital of each province was treated as the representative city, and one urban area and one rural area were selected randomly as survey sites in each city. Women aged 10-70 years were recruited by a multistage stratified random cluster sampling in all the survey sites. 21 Specifically, townships/ streets in each survey site were sorted according to the distance from the county/district government location and were equally divided into two layers. One township/ street was randomly selected from each layer as a sample township/street. In the second stage, in each sample township/street mentioned above, villages/neighbourhood committees were sorted according to the distance from the road where the town government/street office is located and were equally divided into two layers. One village/neighbourhood committee was randomly selected from each layer. In the third stage, all women who met the inclusion criteria were recruited from the survey villages/neighbourhood committees. Face-to-face interviews were conducted by well-trained health service workers to collect information on demographic characteristics, medical history, lifestyle factors, and depressive and anxiety disorders. We assumed that the prevalence of depression or anxiety was 5% in women aged 40-70 years. According to the formula used to calculate the sample size for cross-sectional studies , 7600 women were required. Finally, a total of 12 000 women aged 40-70 years were invited to participate in this survey. We received questionnaires from 10 103 women . Of the 10 103 women, 9900 were included in the current analysis. Participants meeting the following criteria were excluded: incomplete data on hypertension or depressive disorders or anxiety disorders . All participants provided written informed consent. --- Assessment of hypertension Hypertension was defined as participants' self-report of having been diagnosed with hypertension by a doctor and/or currently taking antihypertensive medications. --- Assessment of depressive and anxiety disorders The Chinese version of the Patient Health Questionnaire-9 was used to assess depressive disorders, 22 which has been proven to have adequate validity and reliability. 23 Participants were required to rate each of the nine disorders from 0 to 3 within the past 14 days, with a total score of 0-27. Based on the sum of the PHQ-9 scores, participants were classified as having depressive disorders or no depressive disorders . 24 The Cronbach's α of the PHQ-9 in this study was 0.86. Anxiety disorders were examined using the Chinese version of the Generalized Anxiety Disorder-7 , consisting of seven questions, during the last 14 days, with a total score of 0-21. 25 Participants were classified as having anxiety disorders or no anxiety disorders according to the sum of the GAD-7 scores. 26 The Cronbach's α of the GAD-7 in this study was 0.87. --- Open access --- Assessment of covariates Covariates for this study included age , place of residence , education , employment status , marital status , average monthly household income , drinking , smoking , physical activity , body mass index , diabetes and dyslipidaemia . BMI was calculated as the weight in kilograms divided by the square of height in metres, and classified into four groups according to Chinese standards: underweight , normal weight , overweight and obese . 27 Data on diabetes and dyslipidaemia was obtained according to previous diagnosis reported by the participants. --- Statistical analysis Characteristics were presented as numbers and percentages for categorical variables, and χ 2 tests were conducted for comparison between participants with hypertension and without hypertension. Non-normally distributed variables were described as median and IQR, and were examined between the hypertension and non-hypertension groups using Mann-Whitney U test. First, univariate logistic regression models were performed to calculate the OR and the 95% CI of hypertension and the odds of anxiety and depressive disorders. In addition, multivariable logistic regression models were conducted to estimate the association of hypertension with the odds of anxiety and depressive disorders, adjusting for age, place of residence, education, employment status, marital status, average monthly household income, drinking, smoking, physical activity, BMI, diabetes and dyslipidaemia. Stratified analyses were carried out according to place of residence , education and average monthly household income . Analyses were conducted in SAS V.9.4 software. P values are two-sided, with p<0.05 regarded as statistically significant. --- Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research. --- RESULTS --- Characteristics of study participants Of 9900 women, 18.5% reported having hypertension, while 20.9% and 15.3% experienced depressive and anxiety disorders, respectively. The prevalence of depressive disorders was 28.5% and 19.2% in women diagnosed with hypertension and without hypertension . In addition,21.6% and 13.8% of women who reported hypertension and those who did not report hypertension experienced anxiety disorders . Table 1 shows the characteristics of the study participants according to hypertension. Women with hypertension were more likely to be older and reside in rural areas, have lower levels of education and average monthly household income, have higher odds of obesity, diabetes and dyslipidaemia , and less likely to be employed and married . --- Association of hypertension with depressive and anxiety disorders Table 2 illustrates the association of hypertension with the odds of depressive and anxiety disorders. In the unadjusted model, women diagnosed with hypertension were more likely to have depressive disorders than those without hypertension . After adjusting for age, place of residence, education, employment status, marital status, average monthly household income, drinking, smoking, physical activity, BMI, diabetes and dyslipidaemia, the association of hypertension with the odds of depressive disorders remained significant . In the unadjusted model, women diagnosed with hypertension were more likely to have anxiety disorders compared with their peers without hypertension . After multiple adjustment, women with hypertension had 1.48-fold elevated odds of anxiety disorders than those without hypertension . --- Association of hypertension with depressive and anxiety disorders by SES Online supplemental table 1 exhibits the SES of the study participants according to depressive and anxiety disorders. Women living in rural areas and having lower levels of average monthly household income were more likely to experience depressive and anxiety disorders . Stratified analyses were subsequently performed to evaluate the associations of hypertension with depressive and anxiety disorders by place of residence , education and average monthly household income . After adjusting for potential confounders, hypertension was significantly associated with increased odds of depressive disorders in women living in rural areas , with lower levels of education and with average monthly household income <¥3000 , while the associations were not statistically significant in women living in urban areas , with higher levels of education and with average monthly household income ≥¥3000 . Moreover, after multiple adjustments, hypertension was significantly correlated with higher odds of anxiety disorders in women living in urban and rural areas , with lower levels of education , and with average monthly household income <¥3000 and ≥¥3000 , whereas the association was not statistically significant in women with higher levels of education . We also reported the association of hypertension with depressive and anxiety disorders by place of residence, education and average monthly household income in the eastern , central and western regions of China, respectively. In eastern China, hypertension was significantly associated with increased odds of anxiety disorders in women living in rural areas , with lower levels of education and with average monthly household income ≥¥3000 . In central China, hypertension was significantly associated with increased odds of depressive disorders in women living in rural areas . In western China, hypertension was significantly associated with increased odds of depressive disorders in women living in rural areas , with lower levels of education and with average monthly household income <¥3000 , whereas hypertension was significantly associated with increased odds of anxiety disorders in women living in urban and rural areas , with lower levels of education , and with average monthly household income <¥3000 and ≥¥3000 . --- DISCUSSION In this cross-sectional study of 9900 Chinese women aged 40-70 years, we found that women diagnosed with hypertension were more likely to experience depressive and anxiety disorders than those who did not have hypertension. Furthermore, the positive association between hypertension and depressive disorders was observed in women residing in rural areas and in those with lower levels of education and average monthly household income, while hypertension was associated with higher odds of anxiety disorders in women with lower levels of education. --- Open access One of the principal findings based on 9900 middleaged and older Chinese women is that hypertension was associated with increased odds of depressive and anxiety disorders. Consistent with our findings, a previous metaanalysis including 3578 and 5833 individuals with and without hypertension from six studies reported a significant association between hypertension and depression in elderly populations. 9 Another systematic review and metaanalysis summarising more than four million participants from 59 studies also indicated a significant association between hypertension and anxiety in both cross-sectional and prospective studies. 28 Additionally, a recent survey of the China Health and Retirement Longitudinal Study based on 6273 adults also reported that individuals with hypertension had 1.12-fold increased odds of depressive disorders compared with peers without hypertension. 16 The potential pathophysiological mechanism underlying the link between hypertension and the odds of depressive and anxiety disorders might be partly because microvascular lesions on the prefrontal and subcortical regions could lead to vascular depression and anxiety. 29 Moreover, recent evidence suggested that hypertension and depressive and anxiety disorders shared candidate genes that might result in oxidative stress, low-grade inflammation and hypothalamic-pituitary-adrenal axis dysregulation. 30 In addition, we also found that the impact of hypertension on depressive disorders was only observed in women residing in rural areas and with lower levels of education and household income. In line with our findings, a recent study based on adults aged 45 and older also reported that the association of diagnosed hypertension with an increased risk of depression only occurred in individuals with rural residency and with lower levels of education and household income. 16 Moreover, previous studies exhibited that poor SES was not only associated with higher prevalence of hypertension, but also with higher risk of mental problems such as depression and anxiety. 17 20 Our results also supported these points by demonstrating that women living in rural areas and having lower levels of education and household income were more likely to have hypertension and depressive and anxiety disorders. The possible explanations underlying the influence of SES on the relationship between hypertension and mental problems might be as follows. First of all, people with different SES may be exposed to diverse social environment. For example, individuals with lower levels of household income are more likely to experience higher levels of psychological stress and less likely to have access to advanced medical resources, which might lead to increased risk of mental disorders. 31 In addition, individuals with different SES may have different lifestyles and behaviours. People living in urban areas and having higher levels of education and household income may acquire more health knowledge and have healthier lifestyles, including a well-balanced diet and regular physical activity, which might help prevent or manage physical and mental diseases such as hypertension, depression and anxiety. 16 Our findings may have some public health implications as they indicate that hypertension was associated with increased odds of depressive and anxiety disorders, highlighting the importance of detection and management of hypertension and mental health. In addition, this study also emphasised the significance of socioeconomic inequality in mental health disparities by demonstrating that women with hypertension were more likely to have depressive disorders but only in those with lower SES. The WHO also recommends monitoring and evaluating Open access socioeconomic inequalities in health behaviours as one of the social health determinants. 32 Furthermore, poverty, education, geographical and cultural factors have been reported to be associated with poor utilisation of health services. 33 Prior research also suggested that inequality in health status might be avoidable via adjustable factors including economic and education status and living facilities. 19 Therefore, health education on the prevention and management of hypertension and mental disorders should be more focused on women with relatively low SES in order to minimise inequality in depressive disorders. Furthermore, policymakers should recognise and assess the relationship between hypertension, SES and mental health, and develop effective strategies and interventions to decrease mental health disparities with different geographical locations and diverse levels of education and income. Moreover, expanding access to health insurance is critical to early identification and treatment of hypertension and mental disorders, especially among low SES populations, which might help women with low SES improve their mental and physical health. This study has several strengths. First, the sample size was relatively large. Second, the study used validated instruments to assess disorders of depression and anxiety. Third, the study comprehensively adjusted for potential confounders. There are also several limitations to be noted. First, our study cannot evaluate the causality between hypertension and the odds of depressive and anxiety disorders due to its cross-sectional design and the study only focused on women. Second, we only used urban-rural residency and levels of education and household income to measure SES and did not include other indicators. However, in China, these three indicators have been considered the most important predictors of SES and are widely used to assess SES. 16 Finally, we used selfreported hypertension and did not classify drinking and physical activity in detail. --- CONCLUSIONS In conclusion, our study found that hypertension was associated with increased odds of depressive and anxiety Open access disorders among middle-aged and older women. Additionally, this study indicated that the impact of hypertension on depressive and anxiety disorders was more evident in women with poor SES, which emphasises the important role of SES in the relationship between hypertension and depressive and anxiety disorders. Effective strategies and actions for identification and management of hypertension and depressive and anxiety disorders should be developed and implemented in middle-aged and older women, especially in lower SES populations. Further studies are needed to testify our findings and illuminate the potential mechanisms underlying the link between hypertension and mental health. --- Contributors Conceptualisation, XueW, XZ and BS. Methodology: XueW. Software: XueW. Investigation: DG and XuW. Data curation: XueW and DG. Writing-original draft preparation: XueW. Writing-review and editing: XZ and BS. Project administration: XZ and BS. XZ is overall guarantor for the study and has access to the data. All authors have read and agreed to the published version of the manuscript. Competing interests None declared. Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. --- Patient consent for publication Obtained from patient. Ethics approval This study involves human participants and the protocol was approved by the Ethical Review Committee of the Chinese Center for Disease Control and Prevention . Participants gave informed consent to participate in the study before taking part. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement Data are available upon reasonable request. Data are available from the corresponding author on reasonable request. Supplemental material This content has been supplied by the author. It has not been vetted by BMJ Publishing Group Limited and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations , and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Objectives To investigate the association of hypertension with depressive and anxiety disorders in middle-aged and older Chinese women, and to further assess whether the association was influenced by socioeconomic status (SES). Design Nationwide cross-sectional study. Setting Six provinces of the eastern, central and western regions of China. Participants Women aged 40-70 years were included by a multistage stratified random cluster sampling in 2018 (N=9900). Primary outcome measures Depressive and anxiety disorders were measured by the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7, respectively. Logistic regression models were used to evaluate the OR and 95% CI for hypertension and the odds of depressive and anxiety disorders. Results 18.5% of participants reported having hypertension; 20.9% and 15.3% of women experienced depressive and anxiety disorders, respectively. After adjusting for potential confounders, women diagnosed with hypertension were more likely to have depressive (OR=1.27, 95% CI 1.11 to 1.45) and anxiety disorders (OR=1.48, 95% CI 1.28 to 1.71) than those without hypertension. Stratified analyses demonstrated that hypertension was significantly associated with higher odds of depressive disorders in women living in rural areas (OR=1.34, 95% CI 1.13 to 1.59), with lower levels of education (OR=1.28, 95% CI 1.12 to 1.46) and with average monthly household income <¥3000 (OR=1.33, 95% CI 1.12 to 1.59), while hypertension was significantly correlated with increased odds of anxiety disorders in women living in urban (OR=1.41, 95% CI 1.12 to 1.79) and rural areas (OR=1.53, 95% CI 1.27 to 1.84), with lower levels of education (OR=1.47, 95% CI 1.27 to 1.70), and with average monthly household income <¥3000 (OR=1.45, 95% CI 1.20 to 1.75) and ≥¥3000 (OR=1.49, 95% CI 1.18 to 1.86). Conclusions Hypertension was associated with increased odds of depressive and anxiety disorders among middleaged and older women, especially in those with low SES. Effective strategies and actions for identification and management of hypertension and depressive and anxiety disorders are needed. ⇒ This is one of the largest cross-sectional studies of middle-aged and older women (N=9900) from six provinces in China. ⇒ This study examined the association between hypertension and the odds of depressive and anxiety disorders while adjusting for potential important confounders. ⇒ The study also evaluated the impact of socioeconomic status on the relationship between hypertension and the odds of depressive and anxiety disorders. ⇒ Depressive (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7) disorders were measured by validated instruments. ⇒ Due to the nature of a cross-sectional design, this study cannot evaluate the causality between hypertension and the odds of depressive and anxiety disorders.

Public health must necessarily be concerned with social conditions at the root of many inequities . Public policy that seeks to achieve sustainable improvements in the social determinants of health-income, education, housing, food security and neighborhood conditions, can contribute to positive health outcomes . One approach lies in building capacity for communities to increase their participation and effectiveness in civic engagement, to generate collective action, and to engage private and public institutions to create systems that protect health . Community health workers are members of the communities they serve, have intimate knowledge of community needs and resources, and are considered leaders among their peers . While recognized for their role in impacting health downstream , there is evidence that CHWs can also successfully facilitate community efforts to impact social and structural issues related to health In fact, advocating for individual and community needs is a core competency of CHWs in the U.S. . This report describes preliminary results from Acción Para La Salud an intervention that relied upon CHWs to engage community members in three Arizona border communities in pursuing public policy contributing to sustainable health improvements. The Arizona border population is much poorer, attends fewer years of school, and suffers a higher rate of unemployment than the population of any State. Not surprisingly, these conditions translate into greater health risks, which are exacerbated by the lack of insurance and health care resources . --- Theoretical Background Two theories guide Acción. The first centers on the importance of community engagement in addressing relevant and meaningful policy change. The second postulates an avenue through which CHWs can engage communities in the policy process. --- Community engagement: Gaventa and Barrett presented the results of an international meta-case study that surveys types of citizen engagement . Analysis of 100 studies from 20 countries found that people engaged civically through local associations, social movements/campaigns, and as members of formal participatory spaces such as advisory committees. Outcomes with implications for public policy development include: 1) construction of citizenship; 2) strengthening practices of participation and capacity for collective action; 3) strengthening responsiveness and accountability of states and institutions; and 4) development of inclusive and cohesive societies. Acción used this framework to describe ways CHWs engage their communities as precursors of changes in social determinants of health. --- Policy development: Kingdon's conceptual framework for policy change envisions three streams, problem, policy, and political, which operate independently . In the problem stream, issues are identified and defined based on various indicators or events. The policy stream represents solutions generated about an issue. The political stream describes factors that bring a particular problem into focus or favor a specific policy solution, such as national mood. Policy change most likely to occurs when conditions in all three streams are interconnected. Kingdon calls this alignment a policy window. Change agents can act to open policy windows and/or take advantage of those that have opened. In Acción, CHWs serve as catalysts for change on a local level in all three streams. In the problem stream they interact with community members to identify salient issues. In the policy/solution stream they engage them in creating ideas to improve their community. In the political stream they develop relationships and advance the community's policy agenda with such entities as school districts, health care delivery system, or municipalities. Thus, CHWs both create and seek to capitalize on policy windows in diverse systems. --- Methods Members of an academic-community partnership Community Action Board developed Acción through a community-based participatory research process. The five partnering organizations, which have CHWs as core to their health efforts, included two community health centers, a county health department, a grassroots clinic and a grassroots organization. Each agency identified experienced CHWs on their staff to work on Acción. The eleven Acción CHWs had at least five years of experience. --- Intervention: The CAB training committee developed the Acción community advocacy curricula guide using strategies from existing advocacy and leadership tools. The 18-month training consisted of four participatory and reflective workshops with the Acción CHWs and their supervisors . The CHW supervisors were strategically included to ensure that the CHWs had organizational support for advocacy activities. Activities to foster community advocacy were initiated during the training in which Acción CHWs were asked to talk to community members about issues and identify existing power structures within their communities. After the first year, the CHWs began to identify community advocacy projects based on needs they identified in their contact with clinic patients and participants in CHW prevention activities, during outreach efforts, and in community conversations and meetings. In ongoing technical assistance, CHWs were then assisted in using strategy maps to identify steps to their desired policy outcome . Acción CHWs met regularly with their supervisors and engaged in monthly peer network conference calls to share challenges and successes with their colleagues. --- Data Collection: Acción data collection instruments were determined through a participatory process with partners . The data were primarily qualitative and collected systematically across all five intervention sites to capture the span of their activities. Acción CHWs used encounter forms to document conversations and meetings with community members, groups, and local officials. On the forms they described the issue being discussed, their next step in addressing it, and which of Kingdon's streams they were working in. The strategy maps identified the advocacy outcome and corresponding strategies. Corroborating data sources included quarterly program narratives and technical assistance notes. --- Analysis: Three members of the research team were responsible for analysis. Information on the forms was validated using program narratives and technical assistance notes. The description of the encounter was used to verify whether the CHWs had categorized it in the correct stream. Among the 211 encounter forms, approximately 29% was re-categorized as individual advocacy, community programming or education, leaving 150 forms for analysis. Content from the encounter forms and strategy maps was coded to types of community engagement. --- Results The remaining 150 encounter forms across the five partner agencies were analyzed to ascertain the extent to which CHW advocacy activities were related to Kingdon's theory. The number of forms per agency was 17-55. CHWs most often reported working only in the problem stream reflecting the first step of engaging community members in identifying issues of importance. Many of these encounters were conversations between the CHWs and community members during normal job activities in clinic visits, health education classes, and support groups, and reflected concern over a broad range of issues such as the adequacy of public services, community safety and cleanliness, and activities for youth. Over time, the encounter forms documented a shift from individual to group encounters in the problem stream; e.g., CHWs brought community members together in house meetings or community forums to discuss a problem. Encounters in the problem stream were coupled with the policy stream in 20% of total encounters reflecting activities in which CHWs began identifying and working on solutions to a previously identified problem. A small percentage of policy encounters were activities not connected to a problem identified through Acción . The policy stream and political stream overlapped in 3% of encounters, all of which occurred in one organization in which CHWs had the opportunities to discuss organizational policy change not directly connected to a previously identified problem. In 3% of encounters CHWs began engaging in all three streams, taking their community-generated solution to decision-makers in their agency or town. The remaining 3% of total encounters were political, in which CHWs in one agency held informational meetings with political or organizational leaders . Critical to the Acción intervention is community engagement to address the power relationships that underlie disparities in the social determinants of health. To describe strategies CHWs used to involve community members in the policy development process, we also analyzed encounters by type of engagement. Most often, CHWs used local associations to strengthen practices of participation , typically by engaging their clients in conversations about the wellbeing of their community and what might be done to improve it. The CHWs also involved community members in efforts to increase access to services and to make systems more accountable to community needs , for example through petitions and group meetings with public officials. In two instances , CHWs engaged in activities related to the construction of citizenship, one informing community members of their rights under immigration law, and the other discussing the potential impact of proposed state redistricting on community members. Finally, the strategy maps further documented advocacy strategies and desired outcomes including plans to address transportation infrastructure, clinic hours, safe routes to schools, the safety net for domestic violence victims and sales of energy drinks to minors. --- Discussion Using theories of community engagement and policy change, Acción sought to empower CHWs and their communities to advocate for sustainable change targeting underlying social determinants. To varying degrees across organizations, Acción CHWs encouraged community members to think ecologically about their health and identify advocacy-oriented solutions to improve neighborhood conditions, enhance community opportunities, and increase access to services. In three organizations, Acción CHWs initiated activities in the political stream, in several cases directly involving community members. In looking at types of community engagement, CHW advocacy activities most often focused on strengthening practices of participation, and the majority of these took place within the problem stream. Our findings indicate the value of long-term testing of effectiveness of Acción in identifying specific advocacy activities leading to policy development, and potential policy and environmental changes impacting community health. In the future, it will be important to investigate organizational factors that facilitate or discourage CHW advocacy and determine optimal conditions for successful CHW public health advocacy activities. CHWs community advocacy activities in the Kingdon

Objectives: Public policy that seeks to achieve sustainable improvements in the social determinants of health, such as income, education, housing, food security and neighborhood conditions, can create positive, sustainable health impacts. This paper describes preliminary results of Acción Para la Salud, a public health intervention in which Community Health Workers (CHWs) from five health agencies engage their community in the process of making positive systems and environmental changes. Methods: Acción CHWs were trained in community advocacy and received ongoing technical assistance in developing strategic advocacy plans. Acción CHWs documented community advocacy activities through encounter forms in which they identified problems, formulated solutions, and described systems and policy change efforts. Strategy maps described the steps of the advocacy plans. Results: Findings demonstrate that CHWs worked to initiate discussions about underlying social determinants and environmental-related factors that impact health, and identified solutions that improve neighborhood conditions, create community opportunities, and increase access to services.

Introduction Pre-exposure prophylaxis is emerging as an important tool for controlling the HIV epidemic and a recommended element of combination HIV prevention strategies, including consistent condom use, risk reduction counseling, and HIV testing. 1 Oral PrEP has been shown to reduce HIV infection risk by 92% 2 to 100%. 3 PrEP may be especially useful for populations most at risk for HIV, including men who have sex with men and sex workers. PrEP is recommended for use among atrisk MSM in developed countries, including by US government agencies 4 and professional bodies in the UK. 5 In 2014, the World Health Organization issued recommendations and guidelines for PrEP use among MSM in developing countries. 6 In India, although antiretroviral treatment is available for free in public hospitals, antiretrovirals are not licensed for prevention, and PrEP is not yet provided through public hospitals. Nevertheless, private practitioners and nongovernmental clinics in India are prescribing PrEP for patients, especially for seronegative partners of HIV-positive heterosexual spouses. 7 Anecdotal evidence suggests that PrEP is already used by some educated, higher socioeconomic status MSM in India, who pay out-of-pocket for PrEP with prescriptions from private practitioners. 7 As awareness of PrEP increases among MSM in India, demand also may increase, and PrEP could serve as a significant addition to combination prevention. This is especially important in that amidst an estimated 57% reduction in new HIV infections nationally in the previous decade, 8 national average HIV prevalence among MSM remains 12 times higher than among the general population . Furthermore, this national 'average' among MSM masks substantially higher HIV prevalence of 10-15% documented among MSM in several HIV sentinel serosurveillance sites of the National AIDS Control Organisation, with a trend of increasing prevalence in Chandigarh, Delhi, Goa, and Maharashtra, including Mumbai.9,10 MSM in India continue to be at disproportionately high risk for HIV infection. In order to assess readiness for PrEP and to support future implementation strategies to promote PrEP uptake and adherence, we conducted a qualitative study among MSM in two major Indian cities to understand their perspectives on facilitators and barriers to PrEP use. --- Methods From September to December 2014, we conducted 10 focus groups among a purposive sample of five subgroups of MSM: kothi , double-decker , panthi , gay-identified, and bisexual.11 Participants were recruited through communitybased organizations working with MSM in Chennai and Mumbai . We did not screen participants by HIV status; however, we conducted targeted recruitment at meetings and events designed for HIVnegative/unknown status MSM, rather than at clinics or support groups for people living with HIV. Study inclusion criteria were being age 18 years old or above, self-identified as MSM, and able to provide informed consent. Research staff employed at the CBOs recruited potential focus group participants by word of mouth. Key informant interviews were conducted with health care providers and MSM community leaders in Chennai and Mumbai. The study protocolwas approved by the institutional review boards of the University of Toronto and the Humsafar Trust. --- Data collection We developed a semi-structured focus group interview guide to explore and assess awareness and acceptability of PrEP among MSM. Domains explored were: participants' prior knowledge of PrEP, willingness to use PrEP, perceived barriers and facilitators to future PrEP uptake, preferences for PrEP, access, and anticipated impact on condom use. Focus groups and key informant interviews were conducted in participants' native language . A few key informant interviews were conducted in English. Each focus group participant received INR 300 as compensation for his time. Written informed consent was received from all focus group participants and key informants. After assessing focus group participants' prior knowledge of PrEP, the group facilitator provided a standard explanation of PrEP using a pictorial card in participants' native language. Participants were encouraged to ask questions, and misunderstandings were clarified. Information provided in PrEP factsheets developed by AIDS Vaccine Advocacy Coalition 12 and the US Centers for Disease Control and Prevention 13 were used by focus group moderators to respond consistently to participant queries. Based on results from iPrEx, 2,3 participants were informed that, if taken daily, PrEP provided greater than 90% protection against HIV infection. --- Data analysis Focus groups and key informant interviews were digitally recorded, transcribed and translated into English. Research staff randomly selected 20% of transcripts to check for accuracy in comparison with their respective audio-files. Focus group and interview data were explored using narrative thematic analysis with techniques adapted from grounded theory. 14,15 We developed a codebook based on a priori codes derived from the focus group and key informant interview guides, and existing literature on PrEP acceptability. Inductive/emergent codes and categories identified from the text were then added to the codebook and used in further coding and categorizing of the data. Differences in coding were discussed among two data analysts and senior investigators and resolved by consensus. The analytic focus was on identifying factors that may impede or facilitate PrEP acceptability. Member checking 16 was conducted by discussing findings and interpretations in meetings with field research teams in research sites, with attention to differences in perspectives on PrEP between key informants and MSM focus group participants. --- Results --- Participant characteristics Focus group participants' mean age was 26 years . A majority completed high school, with an additional 32.8% college graduates. Most were employed and unmarried , with 62.3% living with parents or a wife, and 31.1% living alone. Participants were roughly equally divided among kothi , panthi , double-decker , gay , and bisexual sexual self-identifications . Among the 10 key informants, six were MSM community leaders, three physicians, and one a peer counsellor. --- PrEP acceptability The majority of MSM reported they would use PrEP if it became available. Over twothirds reported consistent condom use in the previous month. Table 2 summarizes facilitators and barriers to PrEP acceptability among MSM in India across eight themes, which are described below along with illustrative quotations. --- Awareness about PrEP None of the focus group participants had heard of the term 'PrEP' nor were they aware that ART could be used to prevent HIV infection. Four participants who initially reported that they had heard of PrEP were later found to have mistaken post-exposure prophylaxis for PrEP. When asked whether they knew of any medication to prevent HIV infection, some participants expressed hope that such a medication would be available and expected 100% protection against HIV: Many participants believed that their sex partners-other than cohabiting male or female steady partners-would not find out about their using PrEP. The potential for covert use of PrEP was seen as especially beneficial in situations where a casual or paying partner may not want to use condoms. In contrast, MSM who lived with their parents or wife, or who lived with a steady male partner, anticipated problems in keeping their PrEP use a secret. A kothi living with his parents explained: It will be a big issue in the family. They will think that I am hiding something from them and that's why I am taking medicine. I can't tell them that I am doing such and such thing and so I am taking tablets.If I don't tell them they may even ask the medical shop persons by showing the tablets. Participants were concerned about feeling shamed if their PrEP pills were discovered and further that it might create misunderstanding and marital/relationship discord or that they might be mistaken as HIV infected. As a married participant said: If current use of condoms was consistent, PrEP was seen as an additional burden despite its high efficacy. Some participants expressed that condoms alone were sufficient: ''Why to use both-prevention pills and condoms? Good quality condoms offer better protection… preventive pills are not necessary.'' Some participants, however, accepted the combined use of condoms and PrEP, perceiving PrEP as 'additional protection' in case a condom breaks or slips. As a kothi in sex work said, ''We are already using condoms.But taking pills [PrEP] is useful because condoms sometimes rupture.'' . If I take --- Intimacy and love Participants reported that PrEP would be particularly useful for MSM in HIV serodiscordant relationships. They reasoned that HIV-negative MSM in such relationships would want to have sex with their HIV-positive steady partners without apprehension, as PrEP could protect against HIV infection even if a condom breaks or slips: Even persons who are HIV positive have the right to love. But if we are not HIV positive then we will be scared..I mean I shouldn't get HIV. So I will take pills then. (FGD-6 Panthi, --- Mumbai) Participants further reported differing attitudes toward using PrEP depending on the HIV status of their steady partners. Revealing one's PrEP use to an HIV-positive steady partner was not considered to be an issue; such disclosure was expected to decrease fear or guilt among HIV-positive partners that they might infect their HIV-negative partner. In this case, PrEP use signals concern and supports intimacy. However, HIV-negative participants were concerned about adverse consequences if a male steady partner of unknown or HIV-negative status found out about their PrEP use, as they might be judged as promiscuous or their fidelity questioned: ''If your regular partner sees you taking this, he will think that 'my partner goes somewhere else'… and because of this MSM would not want to take this pill.'' . Thus, in the latter case, PrEP use may engender mistrust and detract from intimacy. --- Attitudes towards PrEP users Participants perceived that PrEP would be particularly useful to MSM who engage in high risk behaviors. Accordingly, they reported that sex workers and MSM who have multiple sex partners would be more likely to use PrEP: ''Those who are in regular sex trade, those who want sex daily can definitely take this,'' . Some participants further reasoned that being on PrEP then means one admits to engaging in high risk behaviors; as a result, there is a risk of being looked down upon by others. As a panthi reported, ''If my friends come to know I am taking [PrEP] they will think ''With how many people he has sex?'' They will start looking at me differently,'' In order to destigmatize PrEP use, participants suggested that it be promoted as an HIV prevention pill for everyone-not just for high-riskMSM. For example, a double-decker said: PrEP should not be branded as useful forMSMalone. They are for anyone who is sexually active.There is no need to declare my sexual behavior.just say that this tablet is to prevent HIV so that anyone can use. Conversely, MSM participants who were open about their sex work, and particularly those whose livelihood primarily depended on sex work, did not express concern about stigma related to using PrEP. In fact, a few reported that being on PrEP would help them to get more clients and that clients might be willing to pay more to sex workers whom they considered to be 'safe' and responsible: If tablets are released they will sell very well-they are for safety, right? MSM in Dhandha [sex work] will ask for more money from their clients.will ask for 2000 rupees instead of 1000 rupees. I am safe now, they will say like that. --- PrEP cost and access Participants preferred having subsidized or free PrEP distributed through CBOs as they argued that most at-risk MSM, including MSM in sex work, are of lower socioeconomic status: Government has to distribute it [PrEP] through CBOs.Condom programming is a good example of it. If it comes through government it will be for free and if it is distributed through CBOs it will not be wasted. Key informants thought the government could provide free or subsidized PrEP through CBOs based on their experiences with existing government-CBO partnerships . In contrast, some participants preferred PrEP to be provided through government health care settings as they were concerned that if PrEP were provided through CBOs, then other MSM might be more likely to find out about their using it and label them as promiscuous. While many participants wanted PrEP to be available in private pharmacies as well, they noted that potential high pricing of PrEP sold through pharmacies may pose barriers in access to even middle-income MSM. Some participants expressed further concern that pharmacies might distribute fake PrEP to increase profits; thus the quality and potency of PrEP sold in pharmacies was potentially suspect. Participants also expressed concern about fear and shame in that pharmacists or others might consider PrEP buyers to be HIV positive, promiscuous, or MSM, and that this would prevent MSM from buying PrEP: --- We may encounter problem in getting the [PrEP] pills from medical shops.any of our neighbors can visit the medical shop; they might ask us why are you taking this medicine… He can inform any of my family members about that. Even the chemist may wonder why I am taking this. --- PrEP characteristics and side effects Once participants were made aware that PrEP, if used consistently, was highly effective in protecting against HIV infection, many expressed that it would be worth taking the trouble to initiate and adhere to a daily PrEP regimen. A few participants, including a key informant, however, remained suspicious of the reported high effectiveness of PrEP as effectiveness data are not yet available from studies conducted in India. The high effectiveness was also perceived to be associated with a high probability of severe side effects. Participants believed that PrEP may affect one's appearance or major organs, one's virility, or may result in sickness and thus loss of wages, including income from sex work: I feel that after all it is a drug, so it will have side effects. If it prevents more than 90% [of HIV infections] then it will have some side effects.many people will think about that-what are its side effects and how major they are, and whether my virility will be affected. If it has little side effects, then we may take. While some participants believed that they could adhere to a daily regimen, others were worried that daily use would be taxing and may detract from PrEP acceptability among many MSM. Accordingly, some participants reported preferences for less frequent dosing or event-driven dosing around times of anticipated increased sexual activity . Some participants questioned why PrEP could not be taken intermittently for short periods of time-for example, only for those periods in which they engage in sex work, which they reported tend to occur when they travel outside their home city. Some MSM reported a preference for long-acting injectable PrEP administered monthly or every two months. An additional advantage of injections was expressed in that it would solve 'storage problems' [i.e., where to safely store PrEP tablets at home or how to carry them during travel]. A participant equated injections with long-term pre-paid cell phone cards and daily-regimen PrEP with short-term cards: --- Injection is similar to having a top-up [pre-paid] card for a large amount; I can talk up to three months. Pills are like 10 Rupees top-up card; it needs to be often purchased-It will last only a day or two. --- Dilemmas due to lack of ART access Community leader key informants articulated concerns about efforts to make PrEP available for wider use in India. One community leader, for example, questioned how MSM will be provided with subsidized or free PrEP through the national HIV program when many people living with HIV still do not have access to free ART. A physician key informant warned about possible emergence of ART resistance due to non-adherence among PrEP users. A community leader, although he supported free PrEP availability,wonderedwhether the government would be able to provide it and wanted MSM not to wait for the government, but to buy it on their own-although this begs concerns about ability to pay: Government is already providing lubricated condoms for free... We can't insist Government to provide this [PrEP] for free or spend money on this. But if they are giving it for free, I welcome it. Or else community should come forward and buy it… They have to invest money for their health. --- Risk compensation Both MSM participants and key informants anticipated decreases in condom use among PrEP users. For example, a panthi reported: If these pills are available in market, then I will stop using condoms.after taking these pills the happiness and fun that we will have while having sex with others will be different .this is like a shield.. whatever comes from outside it has to keep outside only. (FGD-6 Panthi, --- Mumbai) Similarly, a double-decker said, ''MSM will think 'I have already taken the tablet so I don't have to use condoms'-so many will avoid using condoms,'' . Some participants also reported that PrEP users would increase their number of sexual partners or anal sex encounters. A few participants expressed broader concerns that the availability of PrEP might result in relaxation of established and long fought for community norms that support consistent condom use. They feared the weakening of safer sex norms might lead to decreases in condom use even among MSM who do not use PrEP. --- Discussion In this qualitative study with diverse MSM in two major Indian cities, none had previously heard of PrEP. That only key informant physicians and community leaders were aware of PrEP may reflect that it has neither been tested nor licensed in India. Importantly, once PrEP was explained, however, the majority of MSM reported they would likely use it. This suggests that PrEP may be an acceptable HIV prevention strategy among some at-risk MSM in India. Nevertheless, a variety of facilitators and barriers to PrEP acceptability emerged, some of which may be particularly relevant to PrEP implementation in the Indian context. Our study adds to the limited evidence base on factors influencing willingness to use PrEP among MSM in developing countries. [17][18][19][20] Among the facilitating factors, the potential for covert use of PrEP, thus not requiring partner approval or negotiation, was highly valued among a variety of MSM; this included those engaged in sex work, MSM who have multiple sex partners, and married MSM. The particular importance ascribed to covert use may be understood in the context of the reported reluctance to use condoms on the part of clients of male sex workers and broader challenges among MSM in India in talking about condoms or HIV status with steady male or female partners. 11,21 For MSM who were open about engaging in sex work or having multiple partners, procuring PrEP through CBOs did not emerge as a concern. In fact, MSM in sex work reported that they would proudly announce their using PrEP, thereby indicating to others that they are responsible and safe, and even increasing their business. MSM in sex work identified additional advantages of PrEP use, given frequently reported instances of forced sex by ruffians or police-even more so after the recent re-criminalization of same-sex sexual behavior in India. 22 Among both those engaged in sex work and not, the desire to protect one's steady partners also supported PrEP acceptability. Given widespread sexual and HIV stigma in India, 23,24 it is not surprising that MSM expressed concern about PrEP use being discovered by their family members, wife, or male steady partner, fearing negative consequences such as marital and relationship discord, and being ostracized to the point of posing threats of divorce or being ejected from their family home. MSM expressed further concerns about being labeled as HIV positive or promiscuous by their peers, as well as by pharmacists who might dispense PrEP. MSM in the present study were also concerned about PrEP users facing stigma from other MSM, similar to that reported in other contexts. 25,26 Qualitative investigations among MSM enrolled in a phase I PrEP trial in Kenya, 18 and among MSM participants in the iPrex study in Thailand, 26 identified stigma as an important barrier to PrEP acceptability and usage. Broad-based strategies to reduce stigma associated with PrEP are crucial to its acceptability 27 -both within MSM communities and among the general public. Among MSM in our study, PrEP acceptability emerged as higher among those who use condoms inconsistently, with PrEP seen as a ''back-up plan'' or a condom substitute. Some MSM also described concurrent condom and PrEP use as an added burden. Data from the US PrEP Demonstration Project among MSM similarly indicated a positive association between risk behavior and PrEP acceptability; higher risk was a significant correlate of study enrollment. 28 A general preference was expressed among MSM in our study for intermittent PrEP use, which was perceived as less burdensome than a daily regimen, similar to preferences expressed among MSM and male sex workers in Kenya. 18 The recent Ipergay trial supporting the high efficacy of intermittent PrEP suggests eventdriven PrEP 29 may be a plausible option for MSM in India who do not use condoms consistently. Tailored education and implementation strategies for MSM, particularly those of low socioeconomic status, sex workers, and married MSM--each of which face particular challenges in uptake and adherence-may help to support PrEP roll-out in India. A notable concern arose among community leaders who lamented that over a decade of HIV prevention work promoting consistent condom use among MSM as a community norm would ''go to waste.'' Community leaders and health care providers also expressed challenges for PrEP roll-out in the face of suboptimal availability of ART for people living with HIV in India. Such concerns in India appear to be shared, as in a recent international AIDS conference a top Indian government health official reported that India was not ready for PrEP as the focus needs to remain on improving treatment coverage, not on providing ART for prevention. We are aware of only one unpublished qualitative study from India 30 that explored PrEP acceptability among MSM in Pune. Non-use of condoms, wanting a stress-free sex life, and fear of condom failure emerged as reasons MSM might use PrEP. In addition to these factors, which similarly emerged in our study, we identified the pervasive role of stigma as a potential barrier to PrEP uptake. Stigma manifested in wide-ranging concerns about how to store and conceal PrEP from family members, one's wife or steady male partner, and in fears about procuring PrEP from CBOs, due to stigma from other MSM, and from pharmacies. A multi-country survey that included 128 MSM from India found that 75% reported wanting to initiate PrEP; the top two attributes that influenced potential uptake were route of administration and the need for periodic HIV testing. 31 Our qualitative findings complement these results in that diverse MSM reported preferences for intermittent dosing and injectable PrEP; however, the pervasive concerns about stigma that emerged in our study suggest the importance of contextualizing ostensibly product-specific concerns within the sociocultural milieu. That is, preferences for intermittent dosing, long-acting injectables, and concerns about from where and from whom to access PrEP, may be best understood in the sociocultural context of widespread stigma associated with HIV and MSM in India, and the enduring centrality, and often proximity, of family, including the prevalence of heterosexual marriage among MSM. Our previous research with MSM in India similarly identified stigma as a significant barrier to HIV testing 32 and extensive fears about HIV status disclosure. 11 Unfortunately the 2013 Indian Supreme Court decision recriminalizing samesex behaviors in India, reversing a Delhi High Court order that had decriminalized 'homosexual acts' since 2009, is likely to exacerbate these challenges to PrEP implementation, and to HIV prevention for MSM more broadly. 11,33 --- Limitations and strengths The use of qualitative methods and purposive sampling limits the generalizability of the findings. However, our focus was on exploring issues that may emerge around PrEP implementation among MSM in the Indian sociocultural context, in which PrEP usage remains largely unexplored. The results are more likely to be transferrable to other similar settings-cities with diverse MSM and with longstanding HIV preventive interventions. Another limitation is that study participants were primarily recruited through community-based organizations; the acceptability of PrEP may be different for MSM unaffiliated with CBOs serving MSM communities. General acceptability of PrEP in the present sample was expressed despite lack of any previous awareness; nevertheless, concerns about stigma and disclosure of same-sex sexuality, and of PrEP's automatic association with HIV may be even greater among MSM who are not affiliated with community organizations. Also, as this was a small qualitative study, we cannot characterize wholesale differences between different MSM subgroups; however we have indicated possible differences that emerged, and the diversity of the MSM sample is a strength in the breadth of issues explored, including those among married MSM and MSM engaged in sex work. --- Implications Given the established effectiveness of PrEP 2,3 and the WHO recommendation that PrEP be provided to MSM in developing countries, 6 it may be beneficial for India to consider providing free or subsidized PrEP to high risk MSM . PrEP could be provided through existing government outlets in the national HIV program, possibly in a separate wing within existing government-run ART centers. However, concerns about being perceived to be HIV-positive, a barrier to PrEP uptake that arose in our study, suggest the importance of providing alternate sites for PrEP administration, which might include MSM community-based organizations. A current successful model of Indian government-funded targeted HIV preventive interventions employs licensed medical doctors to visit CBOs at regular intervals to prescribe medication for opioid substitution treatment for people who inject drugs, with nurses and outreach workers on site who follow up patients. An analogous model of PrEP administration through CBOs for MSM may help to mitigate predictable barriers to uptake. The use of government ART centers and MSM CBOs also may reduce administrative costs that might accrue with an entirely new infrastructure for PrEP administration. PrEP is already in use in India through private practitioners and a few non-governmental organizations to prevent HIV infection in HIV serodiscordant heterosexual relationships. 7 Explicit guidelines for provision of PrEP to MSM and other at-risk populations should facilitate quality delivery of PrEP through private and non-governmental clinics, a recommendation previously issued in the national consultation on PrEP organized by the Population Health Foundation of India and WHO in October 2013. 7 Importantly, adherence has been identified as the ''Achilles heel'' of PrEP. 29 Data from clinical trials of PrEP conducted in North America and resource-limited settings 2,18,29 have established a clear association between systemic drug exposure and preventive efficacy. 2,34 There is a compelling need for intervention research to identify effective modes for supporting PrEP adherence in real world settings, 35 in addition to education and clinical support to prepare physicians for PrEP administration. 36 Effective interventions, however, are likely to vary across sociocultural contexts, 35 indicating the importance of qualitative research conducted in situ. Findings from the present study suggest that appropriate provision of PrEP should involve exploration with MSM of practical issues that may be expected to impact on adherence: how to safely store PrEP at home in light of concerns about confidentiality, and how to navigate disclosure of PrEP use to one's male partner, wife and family. Our findings also suggest that culturally appropriate interventions to engage community stakeholders 35 and train peer educators 17 may constitute key elements in supporting PrEP acceptability and adherence among MSM in India. When PrEP becomes available in India, both health care providers and community educators need to be aware of concerns that may influence uptake and adherence. PrEPrelated education should be tailored to address client's needs and concerns, such as HIV risk perception, relationship/marital status, partner's HIV status, and attitudes toward condom use. Of particular relevance to PrEP roll-out among MSM in India, gatekeepers such as MSM community leaders and select health care providers that serve MSM communities should be engaged in discussion of the benefits and potential risks of PrEP to the community. As important as is navigating practical concerns, the appropriate engagement of community stakeholders may constitute a key element in reducing the stigma associated with PrEP use and normalizing its role in health promotion for MSM . Importantly, we also identified ethical considerations among community leaders related to PrEP roll-out in a resource-limited setting, in which many persons living with HIV do not have unfettered access to ART. These concerns need to be openly discussed and addressed. 37 Endorsement from these leaders may be critical to the successful initiation of community focused PrEP promotion campaigns and inculcation of positive peer norms about PrEP use. Future survey research among MSM and other key populations in India may help to identify and quantify factors that influence PrEP acceptability and adherence. Policy-oriented research, such as examining cost-effectiveness and the potential number of HIV infections averted, may also be useful in informing policymakers and public health officials about the contribution of PrEP to decreasing the HIV epidemic. A simulation study conducted before the release of the iPrEx study results estimated a substantial positive public health impact of PrEP use in southern India. 38 Investigations to understand health care providers' awareness and willingness to prescribe PrEP to MSM also may be helpful in the Indian context. 39,40 PrEP demonstration projects among MSM to support implementation and thereby maximize PrEP's effectiveness and usefulness in India are also needed. 6,41 To date, a PrEP demonstration project among sex workers through the acclaimed Sonagachi Project has been awaiting approval from the Health Ministry of India. 42 In conclusion, this qualitative investigation suggests that diverse MSM in India may find PrEP an acceptable HIV prevention option. Understanding perceived barriers to PrEP use that emerge at the social/community level and the individual level may facilitate the development and implementation of strategies by the government and community agencies to promote PrEP acceptance and adherence. As recommended by WHO, 6 the Government of India and community-based organizations should seize this opportunity to implement evidence-informed PrEP programs within a comprehensive HIV prevention package to decrease the sustained HIV burden among MSM communities in India.

. Acceptability of HIV pre-exposure prophylaxis (PrEP) and implementation challenges among men who have sex with men in India: a qualitative investigation. AIDS Patient Care and STDs 29(10): 569-577.

Background Marital bereavement and separation or divorce are among the most stressful critical life events in later life. Both events imply a dissolution of social and emotional ties. This deeply affects the attachment system, and requires acceptance of the loss as well as the formation of a new identity and a new perspective for the future. Both events involve the adaptation of daily routines, which can be even more challenging when social, physical and financial resources decline in later life [1]. Grief and psychological distress after bereavement or divorce are normative reactions. For most people, grief intensity weakens to a manageable degree within several weeks or months. After the most intensive period, grief is still present but the loss becomes gradually integrated and no longer hinders the processes of ongoing life. However, some individuals are less able to cope with bereavement or divorce and show severe prolonged grief symptoms or adaptation problems lasting more than 6 months [2][3][4][5]. Some individuals even develop a persistent complex bereavement disorder, which is characterized by separation distress, frequent or disabling cognitive, emotional and behavioural symptoms, such as avoidance of reminders of the loved one, difficulties moving on with life and functional impairment [6,7]. Several theoretical models describe factors that are crucial for an adaptive adjustment to bereavement. The task model identifies four tasks of mourning, namely, accepting the reality of the loss, experiencing the pain of grief, adjusting to an environment without the deceased person, and withdrawing emotional energy and reinvesting it in another relationship [8]. The dual-process model of coping with bereavement posits that a dynamic coping process oscillating between loss-oriented tasks, such as grief work, and restoration-oriented tasks, such as attending to life changes, is essential for adjustment [9]. Coping with loss-oriented tasks involves positive reappraisal versus rumination, revisions of personal goals, positive and negative event interpretation, and expressing emotions toward the deceased. Restoration-oriented coping is focused on attending to life changes, engaging in new activities, distracting from grief, and finding new roles and identities. These models also provide a theoretical background for interventions ranging from self-help groups and pastoral care to psychotherapy. Cognitive-behavioural interventions for complicated grief are often based on three components: exposure, e.g. the confrontational technique of 'revisiting' the deceased person or telling the story of the loss; cognitive reappraisal or restructuring of individual dysfunctional thoughts associated with the loss; and integration and restoration [10,11]. Internet-based interventions increasingly complement grief counselling or therapy [12][13][14][15]. The majority of internet interventions combine the presentation of a web-based self-help programme with minimal but regular therapist contact. In a recent meta-analysis, this internetbased guided self-help approach has proved to be as effective as face-to-face therapy for depressive symptoms, social anxiety disorder and other psychological or somatic disorders [16]. Furthermore, internet-based interventions have advantages over face-to-face therapy. Benefits of internet-based approaches are low threshold accessibility, flexible usage, independent of time and place, usage at a self-determined pace, a high level of autonomy and privacy, and lower costs [17]. These factors may be especially relevant for older adults. However, challenges of internetbased interventions include technological problems and lower computer literacy or unease using computers, which may be more prevalent in old age. Exposure, cognitive reappraisal, and integration and restoration as treatment components have also been implemented and evaluated in two randomized controlled trials of internet-based self-help interventions for complicated grief after bereavement. One 5 week internet-based intervention consisted of two writing assignments a week of approximately 45 min [12]. After every second assignment, participants received an email from a therapist with personal feedback and further instructions. This intervention addressed individuals who experienced symptoms of intrusion, avoidance, or maladaptive behaviour after the death of a significant other. The average age of the 55 participants was 37 years; all were women; 61% had lost a child and 10% their spouses. Effect sizes for the comparison with the waiting group ranged from 0.96-1.74 for different outcome measures. Follow-up measures at 18 months confirmed the stability of these effects [18]. Another internet-based intervention comprised five structured confrontational writing assignments for individuals who experienced the death of a first-degree relative and who were significantly distressed [13]. The average age of the 757 participants was 43 years; 94% were women; 43% lost a child and 30% their spouses. Effect sizes ranged from 0.19 for emotional loneliness to 0.30 for positive mood for short-term follow-up and 0.25 and 0.23 for long-term follow-ups. These effects were mediated by lower rumination. However, grief and depressive symptoms did not improve. Risk and baseline distress were not confirmed as moderators. In contrast with these two studies, Litz and colleagues evaluated an internet-based intervention focusing on self-care, social reengagement and goal-focused activities [14]. No formal exposure or cognitive reappraisal was included. Their randomized controlled trial targeted participants between 3 and 6 months after loss and aimed at exploring whether their intervention could prevent prolonged grief disorder. The intervention consisted of 18 sessions covering about 6 weeks, an initial phone call, and periodic brief emails from a therapist. The average age of the 84 participants was 55 years; 68% were women; 78% lost their spouses. The intervention resulted in Cohens d of 1.10 for the reduction in prolonged grief, 0.71 for depression and 0.51 for anxiety. Finally, a recent study compared an internet-based exposure and behavioural activation treatment [15]. The therapist-guided interventions consisted of six homework assignments over 6-8 weeks and a short feedback after each assignment. The 47 participants were randomly allocated to the two active treatment conditions and a waiting control group. The mean age was 46 years; 92% were women; 40% reported the death of a partner and 60% reported other losses. Both interventions reduced complicated grief, post-traumatic stress, and grief rumination, but only exposure had an effect on depression and brooding levels relative to the control group. Effect sizes ranged between d = 0.07 and d = 1.2. The effects of both interventions were maintained at the 3-month follow-up assessment. To the best of our knowledge, no internet-based self-help intervention has been evaluated for divorced individuals. --- Objectives Based on the task model of mourning, and the dualprocess model of coping with bereavement, we developed a guided internet-based self-help intervention called LIVIA. This intervention addresses individuals who experienced marital bereavement or divorce at least 6 months prior to enrolling in the study and are seeking help for coping with prolonged grief symptoms, psychological distress or adaptation problems in daily life. This study adds to existing knowledge by evaluating an internet-based intervention specifically designed for spousal bereavement and its consequences; testing whether this intervention is equally effective for individuals who suffer from grief and psychological or behavioural adaptation problems after a separation or divorce; and by including loss-oriented tasks, i.e. exposure and cognitive reframing elements, as well as restoration-oriented tasks, i.e. self-care, social reengagement and goal-focused activities. The combination of both components may increase effect sizes compared with previous studies. The severity of grief symptoms is not a criterion for taking part in the study, but will be analyzed as a moderator variable. We assume that the internet-based self-help intervention leads to beneficial effects across the severity dimension of distress. Individuals who have already developed a prolonged grief disorder, but who are not willing to see a counsellor or therapist, may benefit from the comprehensive internet-delivered intervention. For individuals with less severe distress, a timely intervention may help to prevent the progress from a normal grief or separation reaction to a prolonged grief disorder. The objectives of the study are: ( --- Methods --- Study design This study is a randomized controlled trial with an internet-based self-help intervention and a waiting control condition. Figure 1 displays the study flowchart. The study population are adults who experienced marital bereavement or a separation or divorce more than 6 months prior to enrolment in the study. The self-help intervention is embedded in a larger Swiss populationbased longitudinal study on relationships in later life, the LIVES study, IP 212 [19]. The study coordinator uses two separate lists for widowed and separated individuals, to allocate participants to one of the conditions based on computer generated random numbers using Random.org [20]. Participants in the waiting control group receive access to the intervention 12 weeks after the baseline interview. --- Sample size We specified the sample size needed for the different analyses conducting a power analysis based on a probability level of 0.05 and a power of 0.80 with G*Power [21] and a power analysis calculator for structural equation models [22]. To test the efficacy of the intervention compared with the control condition, we expected a large effect of d = 0.80. Power analyses indicated a necessary sample size of 42 individuals for this most basic analysis. For the analysis of several predictor variables, as well as moderation and mediation effects using structural equation modelling, we assumed moderate effects of r = 0.30. Power analyses resulted in a sample size of 138 participants. Anticipating a drop-out rate of 40% at the 6 month follow-up, we aim at recruiting between 72 and 220 participants at baseline. --- Recruitment Recruitment is based on the LIVES longitudinal study and internet-self-help forums. All participants who reported difficulties with adjustment after marital bereavement or separation or divorce in the LIVES study receive an information letter about the self-help programme, with a link to the study website, from the LIVES study coordinator. Additionally, information about the intervention with a link to the study website is posted on several internetbased self-help forums. --- Eligibility criteria All interested adults are required to complete baseline screening questionnaires and a telephone interview for assessing eligibility prior to randomization. Inclusion criteria are: 1. Experience of marital bereavement or a separation or divorce more than 6 months prior to enrolment in the study 2. Seeking help for coping with prolonged grief symptoms, psychological distress or the psychosocial adaptation to a life without the partner 3. Having access to an internet connection 4. Mastery of the German language 5. Provision of informed consent Exclusion criteria are: --- Description of the intervention The intervention is a guided 10-week internet-based self-help programme. During the work with the text-based sessions, participants receive email support by psychologists of the Department of Clinical Psychology and Psychotherapy of the University of Bern. These weekly emails acknowledge and motivate participants in their work with the self-help programme and provide a weekly structure and support for technical problems. Participants can contact their supporters anytime with questions via a contact button in the self-help programme. The email-supporters are supervised by a fully trained psychotherapist. --- Measures Figure 2 gives an overview of the measures with the timing of the assessment. All selfreport questionnaires are completed online. Baseline measurement is at t 0 , post-measurement t 1 is 12 weeks after the start of the programme or waiting condition, post-measurement t 2 is after 24 weeks, and the followup measure t 3 will be completed only by the waiting control group 24 weeks after their start of the intervention, i.e. 36 weeks after baseline. --- Primary outcome measures Grief symptoms are assessed using the German version of the Texas Revised Inventory of Grief [23]. The Texas Revised Inventory of Grief is a widely used measure to assess the severity of grief symptoms. A recent factor analysis identified three factors for emotional response, thoughts, and non-acceptance regarding a loss [24]. The German version of the Texas Revised Inventory of Grief is a 16-item measure to assess the severity of grief symptoms, from 1 = completely true to 5 = completely false. Psychopathological distress is assessed using the German version of the Brief Symptom Inventory, a widely used 53-item measure to assess a broad range of somatic Table 1 Outline of the 10 self-help sessions of the internet-based intervention --- Psychoeducation Information about the self-help intervention, grief reactions, reactions to separation, predictors and treatment of complicated grief 2. Assessment of current situation Information about and assessment of emotions in the context of the interpersonal loss, changes in life since the loss and obstacles for a positive adaptation 3. Fostering positive thoughts and emotions Information about emotion regulation and cognitive-behavioural strategies to promote positive thoughts and emotions Protocols for practising these strategies in daily life 4. Finding comfort Suggestions for self-soothing strategies and exercises to promote positive feelings 5. Self-care Checklists for current physical, emotional and practical self-care, formulation of self-care goals and suggestions for implementing self-care behaviour in daily life 6. Accepting memories and pain Writing tasks to integrate painful memories of the loss into the autobiographical memory and to be able to tell the story of the loss 7. Unfinished business Identification of unfinished business and regrets, writing tasks to formulate unfinished business and to find ways to put issues at rest 8. Creating a new life without the partner Identifying changes in daily life since the loss and sources of support and strengths before and after the loss Information about post-traumatic growth Identifying and activating resources in daily life 9. Social relationships Clarifying current relationships using a sociogram Defining goals related to social relationships, e.g. changing relationships, building up new social contacts, and suggestions for promoting social well-being 10. Redefinition of the relationship to the lost partner Writing a farewell letter to the lost partner: saying good-bye and telling the lost partner about the future importance of the loss and how the participant will continue life without the lost partner and psychopathological symptoms within 7 days prior to completing the questionnaire [25]. Factors include depressed mood, somatic symptoms, information processing deficits, and interpersonal insecurity [26]. Answer categories range from 0 = not at all to 4 = very much. Depressive symptoms are assessed with the German version of the Beck Depression Inventory II [27]. This measure consists of 21 items on a scale from 0 to 3. --- Secondary outcome measures Loneliness is assessed using the De Jong Gierveld Short Scale for Emotional and Social Loneliness [28]. This is a six-item scale with answer categories from 0 = no to 5 = yes. Embitterment is assessed with the short version of the Embitterment Scale, which consists of six items rated on a scale from 0 = I do not agree to 4 = I agree [29]. Life satisfaction is assessed with the German version of the Satisfaction with Life Scale [30,31]. It consists of five items with answer categories from 1 = completely disagree to 7 = completely agree. Session-related outcomes. We included nine items related to specific sessions of the intervention, e.g. self-rated knowledge about grief symptoms, selfcare, self-soothing strategies, satisfaction with social relationships or the current life situation. Items are rated on scale from 1 = very little to 10 = very much. Satisfaction with the self-help programme. Six items assess the evaluation of the quality of and the satisfaction with the intervention, and six items assess effects of the intervention related to mechanisms of change, i.e. mastery experiences, clarification --- Predictors and moderators Computer literacy is assessed using the first seven items of the Computer Literacy Scale for Older Adults [32]. They assess experiences with the computer and the frequency with which participants engage in different computer-related tasks. Demographic variables include sex, age, education, overall self-rated health, and details about the marital history and the loss of the partner or the separation or divorce. Criteria for a persistent complex bereavement disorder according to the Diagnostic and Statistical Manual of Mental Disorders [7] are assessed in the telephone interview. Suicidality is assessed in the telephone interview using the suicidality questions of the Brief Psychiatric Rating Scale [33]. Adherence and completion data, as well as data on the duration and the intensity of the use of the selfhelp intervention are collected within the platform. --- Data collection and management Data are assessed using online-questionnaires programmed in Qualtrics [34]. Data integrity is enforced through a variety of mechanisms, i.e. referential data rules, valid values, range checks, and consistency checks. The option to choose a value from a list of valid codes and a description of what each code means is available where applicable. Checks are applied at the time of data entry into a specific field. In addition, data on the use of the self-help sessions are collected within the platform. All data will be saved in an anonymous way only identified by a code that is not related to the participant's identity. Servers are protected by high-end firewall systems. Only the researchers directly involved in the study have access to the data. --- Statistical analysis Analysis will be conducted according to the intentionto-treat paradigm. Firstly, we will analyze the extent of missing data, explore the missing data patterns and determine the type of missing data . If the missing mechanism is missing at randomization, we will use multilevel regression analyses, which allow a different number of measurement points per participants and are thus less sensitive to missing data. We will include time , group , event and interaction terms as predictors of the outcome variables. Cohens d will be calculated as effect size for all observed outcome variables. To analyze the longitudinal interplay of predictor variables, we will conduct structural equation models. Analysis will be conducted in SPSS and Mplus. --- Discussion The results of this study will provide insight into the acceptance and efficacy of an internet-based self-help intervention for adults who experience grief symptoms, psychological distress or adjustment problems in daily life after marital bereavement or separation or divorce. The outcomes for bereaved and separated or divorced participants will be compared. The analysis of other moderator variables may further aid future selective indication and adaptations for different needs. Limitations of this study include the self-selectivity of the sample. It may be possible that older adults who are willing to take part in an internet-based self-help intervention have more cognitive resources and a higher education level. --- Additional file Additional file 1: SPIRIT 2013 Checklist: recommended items to address in a clinical trial protocol and related documents. --- --- Authors' contributions JB participated in the design of the study and the development of the intervention, and drafted the manuscript. TB participated in the design of the study and the development of the intervention, and programmed the self-help intervention. HJZ conceived the study and participated in its design and the development of the intervention. All authors read and approved the final manuscript. --- Authors' information None. --- Competing interests The authors declare that they have no competing interests. --- --- --- Trial status

Background: Marital bereavement and separation or divorce are among the most stressful critical life events in later life. These events require a dissolution of social and emotional ties, adjustments in daily routine and changes in identity and perspectives for the future. After a normative grief or distress reaction, most individuals cope well with the loss. However, some develop a prolonged grief reaction. Internet-based self-help interventions have proved beneficial for a broad range of disorders, including complicated grief. Based on the task model and the dual-process model of coping with bereavement, we developed a guided internet-based self-help intervention for individuals who experienced marital bereavement, separation or divorce at least 6 months prior to enrolment. The intervention consists of 10 text-based self-help sessions and one supportive email a week. The primary purpose of this study is the evaluation of the feasibility and efficacy of the intervention compared with a waiting control group. The secondary purpose is to compare the effects in bereaved and separated participants. Furthermore, we aim to analyze other predictors, moderators and mediators of the outcome, such as age, psychological distress and intensity of use of the intervention.The design is a randomized controlled trial with a waiting control condition of 12 weeks and a 24-weeks follow-up. At least 72 widowed or separated participants will be recruited via our study website and internet forums. Primary outcomes are reductions in grief symptoms, depression and psychological distress. Secondary outcome measures are related to loneliness, satisfaction with life, embitterment and the sessions. Discussion: The trial will provide insights into the acceptance and efficacy of internet-based interventions among adults experiencing grief symptoms, psychological distress and adaptation problems in daily life after spousal bereavement, separation or divorce. Findings will add to existing knowledge by (1) evaluating an internet-based intervention specifically designed for spousal bereavement and its consequences; (2) testing whether this intervention is equally effective for individuals after separation or divorce; and (3) suggesting adaptations to improve the efficacy of the intervention, selective indication and adaptations for different needs.

INTRODUCTION On December 31, 2019, the first cases of the international rapidly expanding SARS-CoV-2 virus were reported to the World Health Organization , which until then was defined as a "pneumonia of unknown origin." After migrating beyond China's borders, the WHO established that it was a pathological outbreak caused by the Severe Acute Respiratory Syndrome Coronavirus 2 virus, which caused Severe Acute Respiratory Syndrome . Months later, on 11 March, 2020, the WHO declared a pandemic, since the virus had spread exponentially to countries all over the world . Brazil became the third most affected country in the world, in terms of cases, and second in deaths, from COVID-19 . During the SARS-CoV-2 pandemic, social and economic factors shown evidence for national and global social disparities . Lower-income populations suffered most from the systems employed for combating the pandemic, e.g., difficulties in maintaining social lockdowns due to employment and income factors, and less access to health care and basic sanitation . Brazil is an extremely important country for carrying out impact study on the COVID-19 pandemic, since it had a serious outbreak, given its social and economic circumstances, and its complex racial composition. The objective of this study was to statistically verify the mortality rates of patients hospitalized during COVID-19 infection, based on their economic, social, and epidemiological characteristics, and by comparing the main findings with other international studies on the theme . Baqui et al. presented a cross-sectional study with data from the same database source used in this study, when Brazil had 3,254 deaths. It gave results on the mortality factors for COVID-19 including symptoms, age, sex, ethnicity, and comorbidities. Subsequently, THE LANCET suggested that research on mortality from COVID-19 should consider social and biological factors, but also pay attention to ethnic and socioeconomic disparities among patients, emphasizing that the lack of associations between ethnicity and mortality from COVID-19 is of great concern, highlighting a research gap. To contribute to this concern, the main issue in this research is to answer the question: in addition the comorbidities, were social factors important determinants of the COVID-19 mortality in Brazil? This study analyzed variables like comorbidities, age, gender, ethnicity, and geographic region of residence, separately, similar to the cited works. Data were collected from the Hospitalized Severe Acute Respiratory Syndrome database, managed by the Ministry of Health , when Brazil had 331,435 COVID-19 deaths, from February 22, 2020 to May 10, 2021. Additionally, this study carefully analyzed social factors. We used indices for level of education, gender, age, and race, considering the natural divisions made up of Brazilian states, provided by the IBGE Automatic Recovery System from data from the National Household Sampling Survey . We were able to obtain evidence related to social factors and COVID-19. The importance of the subject is that it may reveal disparities among a patient's social condition, and the probability of the disease progressing to death. --- METHODS --- Data Collection Brazilian Ministry of Health maintains a system called Influenza Epidemiological Surveillance Information System , that contains a public dataset about Hospitalized Severe Acute Respiratory Syndrome , from both public and private hospitals. In this study, we collect data from February 22, 2020, when the first case of hospitalization for COVID-19 was registered in Brazil, to May 10, 2021, when Brazil had a total of 1,956,350 epidemiological patient records for people who sought hospital care at all Brazilian states. At that time, Brazil had 331,435 COVID-19 deaths. From that dataset were collected some variables, that are: age, gender, ethnicity, education level, comorbidities, case evolution , the city, and the state where the patient lives. SRAG database also contains patient symptoms, in addition to the aforementioned information. To compose our dataset, we collected indicators on social factor from the National Survey by Sample and Households-PNAD , that were characterized by age, race, gender, and education per state. These indicators were assigned to each patient according to their demographic characteristics and place of residence registered on SIVEP-Gripe. The dataset created allowed us to consider not only health factors to the analyze, but also social. --- Study Design After the data collection, some variables were processed for this study. We created a new variable to set up the region where the patient lives and classified the ethnicity, according to the registered data. Regarding the Brazilian states and regions, although Brazil is divided into five regions, the country was divided into two macro-regions in this study, using their characteristics, similar to the approach by Baqui et al. . The Northern macro-region encompasses the Northern and Northeastern regions, and the Central-South macroregion covers the Central-Western, Southeastern, and Southern regions. This regional division was done for modeling and data analysis purposes for the chosen statistical models. There is a proportionality between the number of COVID-19 cases, the number of hospitalized and deaths with the population of the territorial macro-region, North and Central-South, so they can be compared using descriptive statistics. Also, this division was considered quite natural by Baqui et al. since the socioeconomic factors are similar. To analyze the odds of mortality among races, patients were grouped into two classes, as white or non-white. For the descriptive statistics, we used the names for races as defined by the IBGE defines as: White, Black, Asian, Indigenous, or Mixed-race. Thereafter, there were some selections in the databases to avoid null records following some criteria. Also, the social database do not have data about people under 14 years old. Figure 1 shows data clippings from the initial database and the dataset used in this study. Of the total number of patients selected, 39.4% had died. Of the 1,956,350 records collected from the SIVEP-Gripe SRAG, 1,223,330 patients were classified with COVID-19. 1,056,906 records had variable evolutions filled in. 852,403 records had correctly registered ethnicity. 852,299 listed genders. 840,201 patients were aged between 14 and 100 years. From the resulting database, 840,201 patients, 640,916 were from the Central-South macro-region, and 199,285 were from the Northern macro-region. --- Statistical Analysis We used statistical data to quantify the impact of the COVID-19 pandemic on the number of deaths in Brazil. Our main question is to demonstrate the differences between regions, ethnicities, ages and, comorbidities of patients recorded in the database. The model shown the mortality rates based on variables with a fixed effect for the patients, which were comorbidities and social factors. For this analysis, we used the logistic regression since the central question of this research is related to a dichotomous variable, whether the hospitalized individual evolved to death or not. The prediction analysis was based on the study by Rodrigues and Parreira . Logistic regression is a useful tool for answering the odds of an event occurring. It can predict the binomial outcome of a dependent variable using one or a set of independent variables . Binary categorical variables are often used in empirical research in health sciences, such as History of Abortion: yes or no , Food Security Status: Insecure Food or Secure Food and Food Stability: < 3 times or 3 times , Post-Traumatic Stress Disorder: yes or no . The logit model is usually used when the dependent variable is binary, fundamentally to measure the probability of a given phenomenon. As the response of interest to the dependent variable, the binary logistic model can be represented as shown in Formula 1: P i = E = e b0+b1X1i+....+bnXni / [1 + e b0+b1X1i+....+bnXni ] The maximum likelihood was used to estimate the probabilities of deaths of individuals hospitalized with COVID-19. The objective was to maximize the likelihood function , that is, to obtain the values of the model parameters in what way the probability of observing the values of Yi is the highest possible. In logistic regression, the sample size is fundamental . To apply the model, is also relevant to consider some aspects related to the statistical design. The method is sensitive to multicollinearity , and the most common solution to overcome this limitation is to expand the sample . The function is defined by logit and is related to the probability of patient cases evolving to death, considering their comorbidities and social factors, i.e., using the relative income index. The p risk is calculated below: The values are applied in the formula logit p =ln p 1-p and the odds of death is found as 1-p. Using this method, we calculated coefficients that indicate risks for COVID-19 case with Wald confidence intervals at 99% for the odds ratios. --- RESULTS The patients were registered in the system according to their city of residence. The absolute numbers are shown in Figure 2A, and the numbers of cases per 100,000 people are shown in Figure 2B. Based on research from Baqui et al. , Tables 1,2 show the demographic and comorbidity data between survivors and non-survivors, and their ethnic composition at each stage of the progression of COVID-19. Regarding patients that have comorbidities, there were more registered deaths in the North macro-region in all comorbidities compared to the Central-South. Anova test , suggesting structural health disparities. Even with a different number of hospitalized patients and death in the regions, the previous quantities are relative to their population, which makes the comparison statistically plausible. The older patients had a greater mortality percentage, especially in the North . In that region the non-survivors people over 51 years old are 55.8% and in Central-South they are 44.9%. Table 2 shows a higher proportion of hospitalized deaths in the North than Central-South , suggesting a regional effect. Anova test , shown in the Supplemental Material In addition, there were higher proportions of black ethnicities in deaths in the Central-South region , suggesting an ethnic effect. Anova test shown in the Supplemental Material with the Tukey test result. Figures 3A,B show comorbidity prevalence calculated considering patient, ethnicity, and region, in this case, the FIGURE 2 | Distribution of absolute number of cases among Brazilian states and the Federal District, and number of cases per 100,000 inhabitants. Cases = 840201. AC, Acre; AL, Alagoas; AM, Amazonas; AP, Amapá; BA, Bahia; CE, Ceará; DF, Distrito Federal; ES, Espírito Santo; GO, Goiás; MA, Maranhão; MG, Minas Gerais; MS, Mato Grosso do Sul; MT, Mato Grosso; PA, Pará; PB, Paraíba; PE, Pernambuco; PI, Piauí; PR, Paraná; RJ, Rio de Janeiro; RN, Rio Grande do Norte; RO, Rondônia; RR, Roraima; RS, Rio Grande do Sul; SC, Santa Catarina; SE, Sergipe; SP, São Paulo; TO, Tocantins. Northern or Central-South, for both COVID survivors and deaths. One can see that there is substantial asymmetry between the results, with more deaths in the North. Furthermore, black Brazilians without comorbidities had the highest death rates in both the North and the Central-South . For groups with comorbidities in the North, most deaths were among indigenous ethnicities. In the Central-South, when patients had one or more comorbidity, most deaths were among the black people . The distribution of non-survivors, by age and ethnicity, that was higher for patients aged above 51 in the North and Central-South , as shown Figures 3C,D. For patients aged 14-50, there was greater probability for survival in both regions. Analyzing only the descriptive data, one cannot determine large disparities in survival rates among racial groups according to number of comorbidities and age group. The statistical model allowed us to observe which variables, and to what degree, they influence the individual's odds of mortality based on the coefficient obtained. The validity of the model is shown in Table 3, with p < 0.0001 for all variables, showing that they are explanatory for calculating the probability of an individual not surviving the disease. One can infer that the probability of a patient not surviving are greater for patients with some comorbidities, arranged in order of least to greatest, in Table 3. The three worst factors are neurological diseases, renal diseases, and immunodeficiency disorders. Among the social variables analyzed separately, illiterate patients are more likely to die from the disease, along with patients aged over 50. Patients residing in the Northern macro-region have coefficients that indicate a probability of mortality relative to patients in the Central-South regions, along with women relative to men. The relative income variable, relevant and central to this work, indicates that the higher the index, the lower the chance of patient death. Figure 4 shows the odds ratio for each variable, statistically significant at a 99% confidence interval. According to these indexes, the three comorbidities that most lead the patients to death are neurological disease, renal disease, and immunodeficiency disorders, increased by 1.99, 1.97, and 1.69 times, respectively. One can see that social factors are very significant in increasing risk of death among hospitalized patients. For individuals with lower relative income, for example, odds of death increased 2.45 times. Also, regional factors are relevant, since patients residing in the North and Northeast regions of Brazil are 1.37 times more likely to die, possibly associated with the urgent care and emergency hospital conditions available to patients. --- DISCUSSION This paper presented a study on patient mortality for hospitalizations with COVID-19 in Brazil. To the best of our knowledge, this study gives the highest number of deaths from COVID-19 from both health and social factors using Brazilian data. We were able to verify that social factors were very decisive in determining COVID-19 mortality in Brazil, even higher than the comorbidity factors. This analysis allowed us to observe that patient survival is higher for younger females with fewer comorbidities, in line with results worldwide . Also, other important and new trends for social factors were found in Brazil. Similar to Baqui et al. , significant regional variations were found both in terms of case characteristics and results. São Paulo, Minas Gerais, and Rio de Janeiro states had the most absolute cases. Amazonas, Rio Grande do Sul, and Santa Catarina sates had the most cases per 100,000 inhabitants. These states are important gateways to Brazil. The distribution of hospitalized patients with COVID-19, i.e., the North, at 24% of all patients, and the Central-South, at 76%, is disproportional with the population sizes of these regions. The North holds 36% of the Brazilian population, and the Central-South region 64% . This difference highlights national heterogeneity, and we can therefore hypothesize that hospitalization rates in the North are lower than the Central-South, although this considers disproportionate increases of patients with COVID-19 in Amazonas in January 2021, in a new wave of cases following a new variant of the virus , leading us to infer that the hospital structure in the North was inadequate in attending patients. Some substantial index variations were observed in each region. States in the Northern macro-region tended to have higher risk factors than states in the Central-South region, in alignment with the highest percentage of deaths in the North, according to was even greater than the main comorbidity found . Additionally, individuals living in less populated regions located further North of the country were also more likely to die when they required hospitalization. This information led us to conclude that it is essential to strengthen the conditions of high-complexity care in the public health system, especially for the poorest individuals. Besides, it is important to consider in the public health system planning, more equitable distribution of equipment and medical support. This study had some limitations especially regarding to the existing database. To avoid missing information, we clipped 43.5% from the initial database. These records were about evolution, ethnicity and, gender. Besides, the social database does not consider people under 14 years old, which exclude the possibility to analyze this group. We suggest that in future studies this could be better explored and considered. --- DATA AVAILABILITY STATEMENT Publicly available datasets were analyzed in this study. This data can be found at: https://opendatasus.saude.gov.br/dataset/ bd-srag-2021. --- identify themselves as mixed-race . According to the analysis, both ethnic groups share high-risk factors and high death rates. Of all patients diagnosed with COVID-19 who died in Brazil, the Central-South region has the highest mortality rate per 100,000 inhabitants . However, when the mortality rate is calculated for hospitalized patients only, the numbers are different. The logistic regression results suggested that risk of death is 1.37 times greater in the Northern macro-region than in the Central-South macro-region when a patient is admitted to hospital with COVID-19. It strongly indicates the high complexity health system in the Central-South macro-region. That macro-region is the richer part of the country, despite also have great incoming and poverty inequality. Additionally, the study corroborates information stating that the Brazilian risk group comprises the elderly with comorbidities . Furthermore, it has been demonstrated that hospitalized Brazilian black or mixed-race patients, or those who live in the North, are at greater risk of death from COVID-19. In short, relative income associated with race, illiteracy, and regional issues, are relevant indicators for social aspects related to the COVID-19 pandemic. In Brazil, measures to contain the spread of the virus were managed by local cities. However, concerns about mortality rates are still growing, especially after confirmation of the first case of a new variant from India in Maranhão state on May 22, 2021, which is 50 times more communicable . Across the country, urgent political attention is required, directed toward the importance of vaccination in preventing COVID-19 mortality, especially when the official number of deaths has surpassed the 600,000 mark in Brazil. The estimated relative income index was the most intense result in the statistical model performed, demonstrating that the worse the socioeconomic conditions of the individuals, the greater their chance of death when hospitalized with COVID-19. This index --- ETHICS STATEMENT Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements. --- --- SUPPLEMENTARY MATERIAL The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh. 2022.856137/full#supplementary-material Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher's Note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Copyright © 2022 Rodrigues, da Costa Frizzera, Trevisan, Prata, Reis and Resende. This is an open-access article distributed under the terms of the Creative Commons Attribution License . The use, distribution or reproduction in other forums is permitted, provided the original author and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

On May 10, 2021, Brazil ranked second in the world in COVID-19 deaths. Understanding risk factors, or social and ethnic inequality in health care according to a given city population and political or economic weakness is of paramount importance. Brazil had a seriousness COVID-19 outbreak in light of social and economic factors and its complex racial demographics. The objective of this study was to verify the odds of mortality of hospitalized patients during COVID-19 infection based on their economic, social, and epidemiological characteristics. We found that odds of death are greater among patients with comorbidities, neurological (1.99) and renal diseases (1.97), and immunodeficiency disorders (1.69). While the relative income (2.45) indicates that social factors have greater influence on mortality than the comorbidities studied. Patients living in the Northern macro-region of Brazil face greater chance of mortality compared to those in Central-South Brazil. We conclude that, during the studied period, the chances of mortality for COVID-19 in Brazil were more strongly influenced by socioeconomic poverty conditions than by natural comorbidities (neurological, renal, and immunodeficiency disorders), which were also very relevant. Regional factors are relevant in mortality rates given more individuals being vulnerable to poverty conditions.

A. INTRODUCTION This paper will discuss the altruistic motives of actors implementing social welfare programs originating from the utilization of Islamic philanthropic funds during the issue of identity politics in Indonesia. Islamic philanthropy is included in social community funds collected based on religion and used to achieve prosperity. Maftuhin writes that philanthropy has two elements: voluntary action, which means caring for others through efforts to create welfare, and the public interest, which means action or giving for humanitarian purposes or organizations that provide humanitarian assistance. Islamic philanthropy aims to uphold human dignity for the welfare of the people . Previous research has discussed idealistic motives, which have been described in Firli's research on humanitarian assistance by the International Committee of the Red Cross and another study by Atmeh explaining motives in the Corporate Social Responsibility program. Latief discusses the contribution of Islamic philanthropy to the development of Islamic education in Indonesia. Studies on the politicization that occurred in religion during the Indonesian presidential election in 2019 . No previous research study material discusses the altruistic motives of implementing community welfare programs funded through Islamic philanthropy and occurring during a period of identity politics. Fauziah mentions three philanthropic activities in Islam, zakat, alms/infaq, and waqf. Until now, the power of Islam in Indonesia is still large, as seen from the potential for driving the community's economy through the obligation of zakat. Indonesia has the largest Muslim population, as many as 209,120,000 . Based on the Zakat Potential Mapping Indicator , Indonesia's zakat potential in 2020 is recorded at IDR 327.6 trillion or equivalent to 2.12% of GDP in 2020, IDR 15,434.2 trillion . Zakat is a significant funding potential for community development originating from religious movements managed by one of them non-profit, non-governmental organization, or the Amil Zakat Institution. According to Pujiati's research, the concept of zakat management can be adopted from tax management to make it more effective because of its great potential to assist funding development. The Islamic philanthropic management organization is a third-sector institution outside the government and private sector and a non-profit organization based on religion. According to Hasibuan , an organization is a process of determining, grouping and managing various activities needed to achieve common goals. Non-profit organizations aim to serve the community without prioritizing profit for themselves with three characteristics: organizational resources from donors, producing goods and or services without the aim of cultivating profits, and no ownership . Non-profit organizations engaged in managing Islamic philanthropic funds are shaded by religionbased organizations to welfare the social life of Muslims . However, the current condition of religious movements is being politicized and used as a political weapon of power which invites division and gives rise to egoism in religion and organization. The 2019 Indonesian presidential election has succeeded in creating hate politics due to the contestation and tug-of-war of religious symbols, namely Muslim identity and clerical identity. The politicization of religion that occurs most frequently at this stage is the politicization of language, religious symbols, and narratives, leading to religious selfishness and identity politics . Religious egoism, according to Quintan Wiktorowicz in "Islamic Activism: A Social Movement Theory Approach," is more triggered by efforts to maintain religious symbols for the benefit of the existence of the group or itself. In fact, according to Wiktorowicz , the emergence of egoism in religion is a side effect of a fight between religious actors, such as fighting for influence before the community of followers, occupying positions of power, social positions, and others. Politics is synonymous with power in an area to develop, carried out by competition between individuals and groups. The struggle for positions of power is related to egoism that occurs in politics, so politics has to do with egoism. Identity politics arises because of differences between individuals and, on the other hand, creates "rigidity" in individuals who can trigger actions to elevate themselves and place their interests above the interests of others or are called selfish. KH Yahya Cholil Staquf stated that many religious groups still view interreligious relations as political competition, so religion is used as a political weapon to fight for power . If actors in religious organizations adopt a selfish attitude in managing Islamic philanthropic funds, they have violated the goals of Islamic philanthropy to achieve just prosperity in society. According to Auguste Comte in Taufik , in giving help, humans have two motives, altruism and selfishness. Selfish helping behavior aims to seek benefits for oneself or takes advantage of the person being helped, while altruistic helping behavior is helping solely for the good of the person being helped. Comte calls this helping behavior altruism. The issue of identity politics, which highlights the relationship between power politics and religion, impacts the scrutiny of religious organizations in Indonesia, which continues to this day . There are differences in identity between Islamic Religion-based organizations tasked with managing Islamic Philanthropy funds in Indonesia. The perpetrators of Islamic philanthropy should not mix philanthropic goals with politics because they are not in accordance with philanthropic goals, which should be based on altruism. Altruism is defined by Myers as a motive to increase the welfare of others by utilizing Islamic philanthropic funding that the people and returns for the welfare of the people collect. The community forms the Amil Zakat Institution in Indonesia to collect, distribute and utilize zakat . One of the large national-scale LAZs in Indonesia is Baitul Maal Hidayatullah, under the auspices of the Hidayatullah organization. Hidayatullah is a large religious organization in Indonesia but, until now, has not been directly involved in practical politics in Indonesia. "Since long ago, Hidayatullah did not allow his cadres to engage in practical politics. Hidayatullah wants his cadres to focus on the real sector of good deeds, business charity, da'wah charity, tarbiyah, social, economic development of the people, and so on," stressed the Secretary General of PP Hidayatullah Abu A'la Abdullah. "Politics is for worship"; Politics is not just about fighting for power. Husaini, caretaker of Attaqwa College Hidayatullah Depok, West Java, 2021. "Hidayatullah has made tarbiyah and da'wah the main areas of jihad. Educating the nation's life, educating the public, and enlightening the ummah with Islamic teachings, the values of monotheism, and the principles of the one and only God are essential parts of jihad," said Dr. Nashirul Haq of the Central Executive Board Hidayatullah. This study is based on the motives that actors should have in implementing social welfare programs that utilize Islamic religious philanthropic funds that uphold fair welfare. Altruism motives reflect the goals of Islamic philanthropy, which prioritizes helping others for the welfare of the people who are deserving of those engaged in welfare programs. This discussion is important because of the conditions in Indonesia, which face issues of identity politics that bring the Islamic religion into politics, which negatively impacts the mentality of the people because of political interests that do not reflect religious goals. --- B. METHOD This paper was written based on the results of field research regarding the Motives of Community Economic Empowerment Actors in the Utilization of Islamic Philanthropy in the Hidayatullah Organization in East Java Province. The research used a qualitative approach emphasizing meaning, reasoning, and definition and prioritizing the process rather than the result. The conditions could change according to the conditions in the field . The research subjects were conducted on humans, empowerment actors in the East Java Baitul Maal Hidayatullah environment as an institution that utilizes Islamic philanthropy to become a community welfare program. The objects in this study are empowerment actors from religious-based social organizations who carry out Islamic philanthropy and manifest it as community empowerment, Hidayatullah. The research data comes from primary data obtained from interviews with empowering actors in Baitul Maal Hidayatullah, secondary data from magazines and publications of Baitul Maal Hidayatullah, and documentation data from literature studies of books and journals. Informants who become data sources are divided into several categories and positions as follows: Motive analysis was conducted using discourse texts from interviews with informants from Hidayatullah and Baitul Maal Hidayatullah and expressions derived from published media interviews. The analysis was carried out by connecting the theory and the data results in the field to produce conclusions regarding altruism as a motive for implementing community welfare programs through Islamic philanthropic funds. --- C. RESULTS AND DISCUSSION Philanthropy is one of the three approaches to promote welfare, including poverty alleviation, namely the social service , social work, and philanthropy approaches . Compared to philanthropy based on Islam, becoming Islamic philanthropy is the concept of religious obligations, religious morality, and social justice. The essence of the goals of philanthropy and religion is social justice to prevent the concentration of wealth and create a circulation of wealth to maintain the level of economic equity . The potential for zakat obligations of the Indonesian people is a potential for national development funding that can be utilized to carry out community economic development programs that the community can manage through the Amil Zakat Institution . Philanthropy is also interpreted as "voluntary action for the public good" or voluntary action for the public interest . Maftuhin writes that philanthropy has two elements: voluntary action, which means caring for others through efforts to create welfare, and the public interest, which means action or giving for humanitarian purposes and or organizations that provide humanitarian assistance. The mandate of zakat law No. 11 of 2011 states that the primary goal of the National philanthropic management institution is to participate in poverty alleviation with specific targets. The mandate was assigned to Hidayatullah's Baitul Maal Hidayatullah unit by carrying out fundraising, managing funds, to utilizing funds. The utilization of Islamic Philanthropy funds is closely related to community empowerment activities in the long term. The concept of philanthropy in Islam is firmly based on a paradigm that human dignity is fundamental to be maintained and even fought for. In line with empowerment activities that aim to increase the dignity of layers of society who are currently unable to escape poverty and underdevelopment . The empowerment carried out by Baitul Maal Hidayatullah is carried out by individual actors who run community welfare programs resulting from the utilization of Islamic Philanthropy. Actors in this activity have the urge as humans to carry out an act of welfare activities to achieve community empowerment goals on a certain basis. Every human being has a motivated action or acts with an urge to achieve a goal, including human activities in empowering fellow human beings must have a motive. Motives cannot be observed directly but can be explained by looking at their behavior through stimulation, encouragement, or power generation for the emergence of a certain behavior . Motive actions are actions taken by humans because of a perceived need so that the action aims to achieve a goal . The aspects contained in motifs are based on the definitions of motifs from Bercloon and Steiner, and W.A. Gerungan is an urge from within humans to perform a behavior that is useful for achieving goals. Three keywords describe motives: psychological drives , behavior , and goals. Not all of these three aspects can be seen in real terms to determine the motives of an individual, aspects that can be seen and expressed are the behavior and goals of an individual . --- Figure 1. Three aspects of human action motives The motive in individual psychology is not easy to see but can be identified through encouragement in behavior as described in attribution theory by Fritz Heider . Attribution theory explains the causes of individual behavior and the basis for individuals to perform an action or decide to act in specific ways. According to Heider, in observing social behavior, the first thing that needs to be determined is the cause of individual behavior, external causality , and internal causality . Figure 2. Aspects of motives based on the causes of encouragement to behave According to Heider, attribution is divided into internal or dispositional attribution and external attribution or environmental attribution. Internal attribution is behavior from the person concerned caused by traits or dispositions . External attribution is a person's behavior that comes from the situation of the place/environment or outside the person concerned. Based on the text analysis of the interview results, it can be seen the tendency of the informants' answers with the following data: Based on the results of discourse analysis from the interviews with informants, some of the motivations behind the informants became drivers of the welfare program carried out by Baitul Maal Hidayatullah. Internal motivation comes from the psychology of everyone who in this discussion has a position as people who participate in empowerment. They consciously state that the encouragement widely expressed is a soul calling related to conscience as a human being to choose to do something. In addition to having a calling, there is also encouragement from a sense of empathy for others and aspirations within oneself in carrying out empowerment for certain goals. In addition to internal drives whose causes cannot be inferred from the naked eye but can be identified from the informants' expressions, there are also drives whose causes can be identified because they come from outside the perpetrator. External encouragement comes from the environment around the empowerment actor, which causes an individual to carry out empowerment activities for the community. The mandate of the Hidayatullah Organization as the main organization of the Baitul Maal Hidayatullah is the most frequent expression and is often conveyed by informants. Hidayatullah is a religious organization that upholds religious values in every activity. Movements acting in the name of religion have a holy purpose of serving God without any reason by practicing religious teachings that humans must be patient, helpful, not hateful, not divided, and have no grudges . The movement carried out by Baitul Maal Hidayatullah has a religious goal, Islam, which is oriented towards preaching to the community so that the lives of Indonesian people are directed by religion. Every program driven by Hidayatullah is carried out to support the organization's vision, to build Islamic civilization with the aim of preaching religion. In accordance with the discussion of the theoretical basis, religion has a role in the emergence of motives for empowering actors in Hidayatullah. The teachings of Islam are realized in the formation of Hidayatullah cadres, according to its mission to produce quality cadres in the sense of Islamic and social qualities. Hidayatullah uses the systematic method of revelation, "a method that refers to the events of the revelation of the Qur'an which were given to the Prophet Muhammad SAW sequentially, so it is a method or way of educating people in Hidayatullah so that they can become true Muslims" Ustadzah Retno interviewed, Head of Mushida East Java, Tuesday, 23 August 2022. People in Hidayatullah are first educated to know the systematics of revelation or how to fully embrace Islam as a provider before engaging in congregational life in society. Motives are determined based on the goals and actions carried out by humans because motives are related to actions carried out with the encouragement of a goal. The motives of the perpetrators of empowerment in Hidayatullah can be seen through two elements, the purpose of utilizing the results of Islamic philanthropy and the actions in operating the results of Islamic philanthropy. Activities in philanthropy, which means 'Love others, which comes from the rules of the Islamic Religion, are Zakat, Infaq/Alms, and Endowments which are encouraged to achieve the goal of just human welfare. Religion encourages philanthropy by religion to love one another by assisting in the form of property and facilities to those in need but not as compassion but as a process of selfpurification and peace of mind for zakat payers guided by the Al-Qur'an. an. "Take alms of their wealth, wherewith thou mayst purify them and mayst make them grow and pray for them. Lo! thy prayer is an assuagement for them. Allah is Hearer, Knower." Surah At Taubah 103. The Islamic funding instrument in the form of zakat can support community development in accordance with philanthropic goals, "voluntary action for the public good", which is designed for social change that has a massive impact on social justice with good management of zakat management institutions. Baitul Maal Hidayatullah, which participates in the management of Islamic Philanthropy funds, sees zakat as perfecting the human creed to realize the goal of cleansing the soul, defeating lust and lust that comes from the love of wealth, and protecting humans from becoming selfish humans who only think about enriching themselves . Actions carried out by Baitul Maal Hidayatullah for the welfare of the community are carried out with programs for providing consumptive funds and using productive funds, which are realized through empowerment programs. The third aspect of motive is the goal because every behavior has a goal; Charles N. Cofer explained the direction of behavior because every behavior activity has a goal to be achieved . The goals discussed in this chapter are the goals of the perpetrators of empowerment in Hidayatullah, which are based on philanthropic funding so that the goals of the actors can be broken down into three, the goals of empowerment, the goals of Islamic philanthropy, and the goals of individual actors. individuals in carrying out empowerment. Following are the results of the analysis of information interview data as an empowerer at Hidayatullah: Six levels of heading are allowed as follows: Give help to others "Harus ada kemauan untuk memberikan sebagian keuntungannya untuk sesama selain itu juga adanya panggilan jiwa, dimana Allah menyuruh kita untuk saling berbagi dan menolong sesama" "Infaq dan sedekah adalah penguatan umat, salah satu bentuk ta'awun, saling membantu sesama umat" "Pemberdayaan yang bersifat membantu sesama adalah tugas manusia didunia untuk membantu sesama" "Tanpa disuruh membantu pun kita harus saling membantu" "Masyarakat yang harus dibantu mana yang membutuhkan" "Roda penggerak dibidang dakwah Pendidikan, ekonomi, dan sosial kemanusiaan" "Agar bisa berbagi bersama umat agar mampu membantu masyarakat menjadi berdaya" "Karena ini adalah tugas, kami ditugaskan. Sebagai manusia ini seharusnya menjadi tugas kita" "Ketika kita membantu hajat orang lain maka Allah akan membantu hajat kita di akhirat nanti" "Sebaik-baik manusia adalah yang memberi manfaat kepada orang lain" --- Source: 2022 interview results Based on the discourse text of the interview results in the table, it is known that informants often mention the goals of individuals as actors in community welfare programs, to help others and carry out tasks and orders. These goals become the basis for actors to move and act to carry out empowerment activities. The results of the objective analysis can become data to find out the motives of the actors in Baitul Maal Hidayatullah as individuals who participate in the utilization of Islamic Philanthropy. Hidayatullah's view as the parent of Baitul Maal Hidayatullah regarding the management of zakat is the basis of the spirit of the actors because this religious basis is the basis for moving towards the goal. Hidayatullah's view of the purpose of zakat in human life and Indonesia is as follows: 1. Zakat funds are a form of ta'awun or help to the good done by Muslims to help their brothers and sisters in accordance with Islamic religious law. 2. Utilization of zakat funds becomes a real action to help society towards just welfare. 3. Achieving blessings through the zakat funding process for community welfare. The first basic goal of an empowerment actor being able to move about carrying out empowerment activities is because of assignments and orders. These tasks and orders can be psychological and theological. Psychologically, humans feel they have a duty to help others, and theologically, humans have a duty in this world as caliphs. Khalifah can be interpreted as the role of humans as God's "representatives" on earth who are given the mandate to administer, manage, and utilize the earth and all its contents while remaining submissive and obedient to the rules set by Allah SWT . Humans have tasks that are ordered on a socio-religious basis, as caliphs and other tasks come from orders from the organization that oversees the empowerment actors. Hidayatullah is an organization that has empowerment actors who are regenerated by instilling organizational goals to become the basis for the movement of empowerment actors. The purpose of assisting others can be interpreted as a form of helping individuals to other individuals or a group in need. The word "fellow" is addressed to Muslims or fellow Muslims. Therefore, the purpose of helping that is expressed aims to benefit other people who are still in one bond of the Islamic Religion in accordance with the teachings of Islam "The best human being benefits others. other". The purpose of giving help and help is also explained in altruism, voluntary action to improve the welfare of others without thinking about self-interest . Individual motives in humanitarian activities or helping the community can be distinguished into two categories: altruism and egotistical , opposites. Altruism motives are voluntary actions to improve the welfare of others without thinking about selfinterest , while motives based on self-interest think about self-interest . The theory of altruism put forward by Auguste Comte stated that there are three categories of altruism, psychological altruism, behavioral altruism, and ideological altruism. The term altruism was coined by the French philosopher and sociologist Auguste Comte ). Derived from the Italian word altrui, meaning "to others" or "belonging to others", "altruism" was introduced as an antonym of "egoism" to refer to the totality of instincts about others in humans . The concept of psychological altruism concerns the motives that people have for acting the way they do. Helping others does not count as altruistic unless the perpetrator has the welfare of others in mind as the ultimate goal. In contrast, the concept of evolution or behavioral altruism concerns the influence of behavior on survival and that increasing the fitness of others at the expense of their fitness is altruistic . Sober and Wilson believe that altruistic and egoistic tendencies are adaptive for survival . The concept of altruism can be identified by knowing the act of helping others and the goals for the welfare of others. Based on Sober and Wilson's description of altruism, the motives of empowering actors in Hidayatullah can be analyzed according to the description of the data as follows: Figure 3. Aspects of altruism in the Baitul Maal Hidayatullah BMH carries out zakat utilization activities through two schemes, providing consumptive funds and productive funds through empowerment activities. In order to achieve community welfare, BMH designed an empowerment program that was believed to be able to alleviate poverty in society through synergistic work. However, not all programs can be aimed at community empowerment because basically, our society still needs assistance in the form of consumptive funds. An example of charity activities carried out by BMH is the Muharram Bangkit program, BMH provides compensation packages to orphans and poor people, this program is a direct gift but is carried out on a regular basis and gives priority to children whom BMH or children assisted by Hidayatullah empowers. Even though BMH conducts charity programs, BMH continues prioritizing trust for welfare through community empowerment programs. The implementation of the empowerment program by Baitul Maal Hidayatullah is always enshrined in articles and news both from the BMH website and from the media. This news shows openness to muzakki regarding the mandate of the Philanthropy Fund given to BMH to be managed into a program that helps the community. Transparency or openness positively affects the trust of zakat management institutions , including the disclosure of information submitted to the public regarding programs that have been implemented as a duty and responsibility. Figure 5. Implementation of the productive zakat fund utilization program Source: Website BMH 2022 Baitul Maal Hidayatullah shows actions and goals that tend to help the community toward welfare; these goals and actions can work because there are actors in them. The basis for acting in the welfare program is not derived from political goals but goals as human beings and program implementers. According to what Auguste Comte explained in the law of three stages , the actors run the program because of their belief and intellectual encouragement to behave. "Currently, we are trying before our activities to intervene first in the da'wah program, so we educate them we understand that the BMH of our institution is not political party funds, not funds that depart from sudden funds, no, our funds are in a process the funding, there is a mandate from donors, muzak which we have to use, so we have to deliver these funds in a right target, trustworthy, and successful way." Results of Ustadz Muslim interview, East Java Representative BMH Program, 27 September 2022. The theological basis is the primary key in Baitul Maal Hidayatullah because it must adhere to Islamic religious rules as an Islamic religious institution. Religious belief predicts long-term altruism, as reflected in volunteering and charitable contributions. Gallup Brett Pelham and Steve Crabtree , very religious people tend to have donated some money and have also been reported to have done social work and helped foreigners . "Religion is the center of generosity". Frank Emerson Andrews, Attitudes Toward Giving, 1953. Frank Emerson's words show that faith-based philanthropy can become a center of generosity that is not only temporary but sustainable. According to Latief , philanthropy is interpreted more broadly, namely not only related to the giving activity itself but to how the effectiveness of the activity of "giving", both material and non-material, can encourage collective change in society. Zhao states that religious people are more altruistic than non-religious people because all central religious teachings explicitly encourage good behavior toward all beings. Therefore, the basis of religion without politics can create human motives as a driving force for empowerment programs to produce actions that can realize people's welfare. Altruism is the basis of the actors in Baitul Maal Hidayatullah as philanthropic administrators to carry out their duties with the aim of helping others and the welfare of the people. Religious organizations that prioritize the welfare of the people will act based on altruistic motives because of their moral responsibility as religious people. --- D. CONCLUSION The motives of the perpetrators of community welfare programs, when associated with a religious basis, have a relationship between religious philanthropy and religious goals, which reflect altruistic motives. Therefore, in terms of altruism, starting from the encouragement, actions, and goals of the actors in Baitul Maal Hidayatullah, they have similarities that lead to community welfare. Self-religious and psychological encouragement enables the actors implementing the community welfare program at Baitul Maal Hidayatullah to act and behave to help the community achieve prosperity with empowerment programs. Welfare is a long-term goal of empowerment and a goal that is an aspect of the altruistic motive. The primary foundation of Hidayatullah's organization has a strong role in instilling the basis of religious and organizational rules so that people within Hidayatullah's environment cannot practice politics. The absence of interest in politics makes the goals of altruism more achievable and embedded in welfare program implementers. BIBLIOGRAPHY Adi, I. R. . Psikologi Pekerjaan Sosial, dan Ilmu Kesejahteraan Sosial: Dasar-Dasar Pemikiran. Jakarta: Grafindo Persada.

The Amil Zakat Institution (LAZ) is an institution that serves the community for the welfare of society through Islamic Philanthropy funds. But the LAZ program is not yet compatible with other welfare goals; there is an issue of politicization that befalls religious organizations so that the focus of amil zakat institutions tends not to lead to community development. This paper will discuss the altruistic motives of implementing social welfare programs amidst the issue of identity politics in Indonesia. This research is based on a study of the motives for helping altruism in accordance with the goals of just social welfare reflecting Islamic philanthropy's goals. The research uses a qualitative approach with motive analysis using discourse texts from interviews with informants from Hidayatullah and Baitul Maal Hidayatullah (BMH) linked to theory to produce conclusions. The study results explain that aspects of altruism, starting from the encouragement, actions, and goals of the actors in BMH, have similarities that lead to community welfare so that altruism motives reflect what they do as implementing welfare programs based on the Islamic religion. Hidayatullah does not carry out practical politics as a basis for actors in the empowerment process to focus on community welfare.

Introduction Personal networks develop and evolve continuously throughout the life course . Some scholars suggest that network size is bellshaped as a function of age . On average, the size of the network initially increases with age, peaks at young adulthood, and decreases monotonically after middle adulthood . However, others claim that the network dynamics in later life can be more complex . To capture such complexities, one needs not only to examine the structure of older adults' personal networks, but also to investigate the social backgrounds and contextual factors that help shape these networks. Life course transitions and changes in social context result in exceptionally high network turnover rates for older adults . However, peripheral ties are especially likely to dissolve as individuals age, as compared with inner ties . This illustrates an important phenomenon, namely, that different types of social ties have different likelihoods of dissolving as the social context shifts. This motivates my research questions: How do the size and structure of personal networks evolve as individuals age? To what degree do social disadvantage and contextual factors matter for network dynamics in later life? A well-connected and well-structured personal network contributes to an individual's well-being. But people of different sociodemographic backgrounds have different chances of building and maintaining such a network. Empirical studies have shown a positive association between advantageous personal networks and other life outcomes, including lower mortality risk, and better physical health and emotional well-being . The supporting role of personal networks becomes more substantial in later adulthood, as older adults tend to rely on close ties for social support, especially once their health substantially declines . Social disadvantage is associated with less desired network positions as well as less favored network characteristics. However, both these lines of research are faced with the problem of reverse causality. Is it that a good social relationship leads to advantage in health, living situation, and economic standing, or do those same factors contribute to both a good social relationship and other positive life outcomes? In other words, the success in social relationships and other life outcomes could be the result of some other social factors, such as favorable sociodemographic background or contextual factors. Moreover, social contexts and networks could co-evolve as adults age. One way of compensating for this is to incorporate existing social disadvantage indicators and dynamic contextual factors simultaneously in the analysis. Among the relevant factors, the residential, working, and health contexts are often considered to play a key role in shaping personal networks . Therefore, I include all these factors in my models. This paper has two main parts. First, I present how older adults' personal networks change over a ten-year period. Specifically, I show how the size, composition, and frequency of contact change. These are defining factors of a network's structure and function . Second, I examine how disadvantaged backgrounds and shifts in contextual factors correlate with network features. By comparing the network features of disadvantaged groups and the reference group, one can see how pre-existing disadvantage can impact network size and structure. By including the contextual factors, one can see how contexts can alter network size and structure. I explore how networks are constrained by pre-existing social disadvantage but can be altered by the social contexts. In the meantime, one can also see how personal networks compensate for pre-existing disadvantages. To achieve the analysis goals, I apply between-within models. The between-individual effect compares network structure and size differences across social groups. The within-individual change shows how contextual factors and personal networks evolve for an individual across time. The results have significant implications on how social networks are associated with social inequality. --- Social disadvantage, context, and network dynamics in later life There is still debate about how personal networks evolve during the aging process. On the one hand, social disengagement theory claims that as individuals grow older, they become less engaged with their network members . This theory indicates that both network size and frequency of contact decrease as adults get older. Along this line of research, socioemotional selectivity theory proposes that as older adults age, they tend to downsize their networks in a way which benefits emotional well-being . They prioritize the social connections which satisfy their emotional needs, instead of social ties that give them useful information or financial benefits . On the other hand, some scholars advocate that personal networks remain relatively stable as individuals age . These scholars acknowledge the potential network turnover that older adults experience due to changes in social contexts. For instance, retirement, health decline, relocation, and adult children moving away can all fracture existing ties of older adults. However, these scholars suggest that older adults actively adjust for the loss of ties and make efforts to build new connections. As a result, older adults achieve homeostasis in network size . The structure of older adults' networks is as vital as the network size. Different types of networks, such as diverse networks, family-centered networks, friend-centered networks, and restricted networks, usually indicate different accessibility to social resources . Moreover, the type and structure of social networks are associated with health outcomes, such as life expectancy, health habits, and quality of life . More diverse networks are associated with better mental and physical health , while restrained networks are linked to inferior mental health . In older adulthood, family-based networks are prevalent and of great importance for older adults . Older adults with family-based networks are less likely to experience depressive thoughts and are more satisfied with their quality of life . This paper examines the size and structure of the confidant network because its members are essential for supporting older adults as age increases. I expand on work that has studied how age, contextual factors, and sociodemographic background are intertwined and impact the close ties of older adults. The answer to this question contributes to our understanding of the role of personal networks in aging and the corresponding consequences for social inequality. Pre-existing social disadvantage is associated with less favorable network characteristics. Previous studies have used limited education and racial minority status as the key indicators of social disadvantage . Older adults with higher education are more likely to have their adult children as confidants despite geographical distance . Race and ethnicity affect the size and composition of an individual's network. Some scholars suggest that Black Americans are more likely to have a smaller network with higher frequency of contact. Their networks tend to be more family-based than other racial groups . Older Black American adults and those who did not attend college are more likely to experience instability in their relationships with their adult children . This might cause them to lose access to important resources and support since parent-child ties are essential for older adults. Contextual factors are the elements of the social environment in which one is embedded, and/or which describe essential changes in the life course which affect one's social interactions. Contextual factors including neighborhood environment, job entry, retirement, functional health decline, change in mental health status, and relocation can also lead to personal network changes . Neighborhood environments have significant implications on social inequality in the US . The community in which an individual lives is closely linked to their income level, educational outcome, high risk behavior, delinquent activity, criminal involvement, and mental and physical health . Based on a randomized social experiment, Ludwig et al. found that moving from a disadvantaged neighborhood to a less disadvantaged neighborhood benefits both mental and physical health, which in turn contributes to a higher level of life satisfaction. Disadvantaged neighborhoods are more likely to experience higher rates of crime and homicide . Social cohesion within a neighborhood is relevant to the networks of the residents. Disadvantaged neighborhoods are associated with smaller network size for older adults . Older male adults who live in disadvantaged neighborhoods tend to have less frequent contact with family and friends . The influence of residential contexts on individuals' personal networks persists across different life stages . Working status also impacts network composition and structure . Retiring adults are less likely to maintain co-worker relationships, which results in a decline in network size and a more closely knit network . The closeness of social ties from work and the timing of retirement both impact how the network changes. Peripheral ties have a higher a probability to dissolve during the transition to retirement, regardless of occupational type . Some scholars suggest that networks become more stable after the transition to retirement. Other life-course changes, such as mental health decline, functional health decline, and the transition into caregiving roles also affect how networks change in the long term . For older adults, transitioning into caregiving roles might put a lot of strain on their psychological well-being and lead to conflicts with family members . Apart from impacting personal networks directly, social context can also be a moderating factor between networks and other life outcomes . The studies above provide us with broad knowledge of the essential factors shaping personal networks. As mentioned above, I take a dynamic perspective and track the changes in the contextual factors as well as the changes in personal networks across time. Social networks are dynamic in nature and the stability of networks differ for different social groups. Likewise, contextual factors can be unstable, especially for disadvantaged groups . Moreover, research in this area often focuses either solely on social disadvantage or contextual factors. Pre-existing social disadvantages and contextual factors may be closely intertwined. Individuals from disadvantaged social backgrounds have higher likelihood to be trapped in less favorable social environments and encounter more instability and insecurity throughout the life course . As a result, pre-existing disadvantage and the evolving contextual factors together shape the personal network of an older adult. Including both pre-existing social disadvantages and social contexts in the analysis allows one to distinguish between the impacts due to each separate factor. Examining the co-evolution of social environments and personal networks can help solve the problem of reverse causality. Furthermore, instability in personal networks can affect individuals' health and socioeconomic outcomes. Some research has shown how various life events impact network size and structure over an extended time period. Despite the innovation and advancement in these studies, most are only based on a small number of observations which are not necessarily representative for an entire nationwide social group. My study contributes to this line of inquiry by analyzing changes in personal networks and their association with evolving contextual factors as well as pre-existing social disadvantage, based on longitudinal and population-based data. I claim that network change is intertwined with preexisting social disadvantage and contextual factors. On the one hand, people from disadvantaged backgrounds are more likely to rely on resources provided by their close social circles. Thus, they have the motivation to sustain existing network ties and seek potential new connections. On the other hand, individuals from underprivileged backgrounds might have limited resources to maintain or construct social ties. Previous theories, such as social convoy theory, suggest that close ties are less likely to dissolve than peripheral ties . Socioemotional selection theory also emphasizes the value of close ties and how older adults make great efforts to preserve these ties. Although close ties are more enduring than peripheral ties, they can still be highly dynamic in later life . By using longitudinal and nationally representative data on older adults' confidant networks, this paper captures the change in close ties over a 10-year period in later life. Furthermore, I examine how social disadvantage, contextual factors, and changes in these elements are associated with the change of network size and structure over a long time period in later life. Based on previous research, I propose the following hypotheses: Hypothesis 1 On average, network size, frequency of contact, and proportion of kin tend to decrease over the long term as age increases. Hypothesis 2 For older adults from disadvantaged backgrounds, personal networks tend to be smaller in size with a lower level of diversity. Hypothesis 3 Changes in the contextual factors can alter network size and structure, even after controlling for preexisting social disadvantage. --- Data and methods --- NSHAP data This study uses three rounds of data on 1,168 older adults from the National Social Life, Health, and Aging Project . NSHAP is the first nationally representative dataset on community-dwelling older adults egocentric network change in the United States. This study collected detailed information from older adults, including sociodemographic backgrounds, egocentric networks, marital and sexual relationship history, health, and neighborhood environment. This paper mainly utilizes the network section and sociodemographic background section. The first round of data was collected in 2005/2006 with a sample size of 3,005. The second round and third round of data were collected in 5-year increments. At Round 1, the older adults were aged between 57 and 85 years old. The sample of this study consists of older adults who were surveyed in all three rounds. The weighted and conditional response rates for Round 1, Round 2, and Round 3 are 75.5%, 89%, and 89.2%, respectively . --- Measures The outcome variables are network size, frequency of contact, and proportion of kin. The confidant network is an egocentric network with the respondent as the center of the network. These egocentric networks were elicited by a widely used name generator. Specifically, each respondent was asked to give a list of names of people with whom they discussed important matters in the past 12 months.1 Three aspects of the egocentric confidant network are of most interest in this paper, namely, network size, average contact frequency, and network kin composition. Network size is the number of close contacts that older adults have in the egocentric network. The frequency of contact captures how often the ego talks to the alters on average. The proportion of kin is the percentage of kin members in respondent's confidant network. The explanatory variables can be divided into two groups: sociodemographic characteristics and contextual factors. For sociodemographic characteristics, I focus on respondent's race and ethnicity and educational attainment. These two variables are often used to identify social disadvantage. For race and ethnicity, I generated three dummy variables with White respondents as the reference group. Racial groups and educational attainment are treated as time-invariant variables. For contextual factors, I primarily examine respondent's functional and mental health status, working status, and neighborhood ties. Ideally, all the contextual variables should be time-varying variables. However, some variables are only available in a certain round of the survey. For instance, neighborhood ties are only collected at Round 2. It is still meaningful to include these screenshots of context to present a whole picture of how contextual factors impact network dynamics. Other contextual variables are all treated as time-varying variables in the models. Functional health, mental health, and working status were collected at all three rounds. The range for self-rated mental health is from 1 to 5, 2 with larger scores indicating better mental health. Functional health is evaluated by respondent's difficulty in ADL and IADL activities. The range of the functional health score is from -27 to 0. 3 0 represents that there is no difficulty in ADL and IADL activities, while more negative values represent more difficulty in the ADL and IADL activities. Working status is a binary variable, documenting whether the older adult worked for pay in the last week. Control variables include gender, age, marital status, and household size. Previous research has suggested networks and their change could differ among people of different gender, age, marital status, and household size. Based on the design of the NSHAP survey, gender is treated as a timeinvariant variable. Age, marital status, and household size are treated as time-varying variables. Age is scaled by 10 to demonstrate the coefficient of age more clearly, and to show the differences between 10-year age groups more straightforwardly. Household size measures how many people live in the household being interviewed, including the respondent. --- Methods and models The main model that I utilized is the between-within model . I use some key social disadvantage indicators and contextual indicators to predict the change in network size, frequency of contact, and network composition. Three models were estimated using the explanatory variables and controls to predict the change in network size, the frequency of contact, and network kin composition in later life, respectively. I estimated the following between-within model: where y it is the network characteristic, x it,m is individual i 's explanatory variable m at time t , x i,m is individual i 's average value of variable m over ten years, W,m are the within-individual estimators, B,m are the between-individual estimators, and c i,k is a set of control variables. The coef- ficient W,m means each unit of within-individual change in explanatory variable m is linked to W,m change in the y it = a i + M ∑ m=1 W,m x it,m -x i,m + M ∑ m=1 B,m x i,m + K ∑ k=1 k c i,k + e it outcome variable y it . One strength of between-within mod- els over OLS models is that they separate within-individual effects and between-individual effects. This advantage is especially valuable for the time-varying explanatory variables that I study. The within-individual estimator captures how changes in a feature of an individual over ten years are associated with changes in network structure. --- Results Table 1 shows the descriptive statistics of the variables in the models. The upper panel of the table shows the concentration tendency of the sociodemographic variables. 76% of the respondents are White. Black, non-Black Hispanic, 4 and other race and ethnicity constitute 12%, 9%, and 2% of the sample respectively. 37% of the older adults only graduated from high school or less. On average, the mean of the self-rated mental health score is 3.9, per the range of 1-5. At Round 1, the average score of functional health is -1.4. This suggests that the respondents have moderate difficulty in ADL and IADL activities, on average. Over ten years, mental health scores remain relatively stable, while functional health declines monotonically. At Round 1, 40% of the respondents worked for pay recently. The average household size at Round 1 is 2, meaning that, on average, older adults live with at least one other person. The average size of older adult's confidant network at Round 1 is 3.65. This number increases slightly to 3.92 five years later and remains steady in the following five years. On average, older adults talk to network members more than once a week. The frequency of contact decreased slightly in the following 10 years. At Round 1, 67% of the network members are kin. The composition of kin in confidant network decreases in the next 10 years, on average. As older adults get older, their confidant networks tend to shrink more. At the same time, the frequency of contact and proportion of kin tend to decrease. My first research question asks how networks change as age increases. The between-and within-individual coefficients of age in Table 2 show that as an individual ages, the size of the social network increases while the frequency of contact and proportion of kin decrease. But if the results from the lower panel of Table 1 are combined, one can see that for the entire sample, the absolute change in network size, frequency of contact, and proportion of kin is relatively small. Based on Table 1, network size has a small increase while the frequency of contact and proportion of 2 I assigned the scores to different mental health categories as below: 1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent. Higher scores indicate better mental health. 3 Similar to previous research, I assigned scores to each of nine functional health categories as follows: 0 = no difficulty, -1 = some difficulty, -2 = much difficulty, -3 = unable to do. Scores closer to 0 indicate better functional health. 4 The race/ethnicity category in this paper is the same as the category in the original data from NSHAP. NSHAP divides race and ethnicity into four categories: 1) White, 2) Black, 3) Hispanic, non-Black, 4) Other. kin decrease monotonically for the entire sample, on average. Hypothesis 1 is partially supported. In addition, none of the between-individual coefficients are statistically significant. This indicates that no cohort difference in network size and structure is observed. However, this might be due to the small sample size of each cohort in the overall sample. When performing more detailed analyses by social groups, I find statistically significant differences between people from different social groups. The upper panel of Table 2 shows the association between pre-existing social disadvantage and network size and structure. As suggested beforehand, racial minority status and lack of college education are indicators of social disadvantage. In the upper panel of Table 2, the coefficients suggest that older Black and Hispanic adults tend to have a smaller network size than older White adults. At the same time, older Black and Hispanic adults tend to have higher frequency of contact. Older Hispanic adults tend to have higher proportion of kin in the confidant network. These findings align with previous studies. Lower educational level is associated with a smaller network size, more frequent contact, and higher proportion of kin in the confidant network. These results suggest that people from disadvantaged groups tend to have smaller networks, a higher frequency of contact, and are more likely to have kin-centered networks. Hypothesis 2 is partially supported. Previous literature has suggested that a larger network size and a more diverse network are more beneficial. My findings suggest that older adults from disadvantaged socioeconomic backgrounds are less likely to have these beneficial networks. However, pre-existing disadvantages do not dictate the size and structure of individuals' networks over a longtime period. During older adulthood, as contextual factors shift, network features also shift. Contextual factors play an important role in shaping older adults' networks, net of pre-existing social disadvantage. Mental health is an important indicator of network change. Better mental health is associated with more frequent contact with confidants and higher proportion of kin. As mental health improves, the average frequency of contact increases. No significant difference in network change has been found between those older adults who worked for pay recently and those who did not. However, transitioning into working for pay is linked to more frequent contact with network members. The cohesiveness of the neighborhood in which older adults live also has implications for network change. Older adults who live in a more cohesive community tend to have a larger network size, higher frequency of contact, and lower proportion of kin. These results suggest that, despite preexisting social disadvantage, positive contextual factors can lead to increase in network size, more contact with friends, and lower proportion of kin. Hypothesis 3 is partially supported. As for control variables, older adults who were married or had a partner present at Round 1 tend to have a higher proportion of kin than those who were not married or did not have a partner present. Those who transitioned into being married or having a partner present increased their proportion of kin in the confidant network. Older adults with a larger household size are likely to contact network members more often. Moreover, a greater proportion of these contacts are kin members. --- Conclusions and discussion The changes in the size and structure of close social ties impact essential life outcomes of older adults . However, what leads to these changes is not yet fully understood. Socioemotional selectivity theory and social convoy theory claim close social ties are more enduring than peripheral or weak ties in the aging process. The core question these theories address is which type of social ties are more enduring throughout the life course. However, even the strongest ties dissolve or change over a long-time period . Moreover, the pattern of network change differs for different social groups. For instance, Suanet and Huxhold's study on two Dutch cohorts suggests that the 1938-47 birth cohort is more likely to have an increase in network size around retirement age than the 1928-37 cohort, which is related to increased educational level and more diverse social roles. For another, the size and structure of the convoys of an adult are contingent on their own position in the network .What previous scholarship leaves unanswered is how the change in the strongest ties across time differs by socioeconomic status. To what extent do pre-existing social disadvantage and contextual factors shape one's closest social network ties? Based on the longitudinal study of older adults egocentric networks, I find that the pattern of network change in later life is contingent on the social background and the contextual factors in which individuals are situated. Additionally, I did not observe a monotonic decrease in network size over the ten years as previous studies suggested. My findings suggest that pre-existing social disadvantage is associated with less favorable network features for older adults. Older adults who did not attend college have fewer close friends with whom to discuss important matters and have a higher proportion of kin in their close social circles. Likewise, Black older adults and Hispanic older adults have fewer confidants and are more likely to have kin as their close friends. Some scholars argue that the rule of homophily based on race and ethnicity might contribute to a smaller network size for older Black adults . However, studies have shown that homophily based on racial and ethnic background in the friendship network does not benefit racial minorities . A larger and more diverse network often indicates more social resources and benefits are available from the network members . However, whether an individual can build and maintain such advantageous networks largely depends on their socioeconomic status and pre-existing resources. These findings align with previous scholarship. In the meantime, I find that less educated and racial minority older adults have a higher frequency of contact with confidants, compared to their counterparts. This could be because these older adults are more reliant on their network members for support and resources on a daily basis. I propose that contacting network members frequently is a necessity and functions as a strategy to activate the potential resources in the network. Close social ties, in this case, act as a complementary resource to make up for the lack of financial, cultural, and political resources available for these older adults. I claim that social contexts and the shifts in these contexts can alter personal networks in significant ways, even though pre-existing social disadvantage restrains the size and diversity of personal networks. For instance, neighborhood cohesion is positively associated with the network size and negatively associated with proportion of kin. The social capital at the community level can be transferred to an individual level. Older adults living in a cohesive community have more chances to meet people outside of their family and build connections. A welcoming community also encourages people to initiate contacts and stay connected. On the other hand, instability in a variety of key social and personal variables might cause shifts in the network and the pattern of network change . Also, I find that mental health is linked to the size and structure of the close social circle. Older adults with better mental health tend to contact their close friends more often. Transitioning into better mental health or transitioning into working status is associated with more frequent contact with confidants. Better mental health empowers older adults to reach out and activate their social capital. If retired older adults return to work, this can still ignite social contact and connections. Based on these findings, I propose that older adults make efforts to adjust to changes in their networks during the aging process. While holding the social background constant, within-individual changes in personal networks can be seen as the consequence of individual's efforts to cope with changes in the social context. Since a diverse and wellconnected network is associated with more positive life outcomes , older adults from disadvantaged backgrounds have more motivation to initiate contacts and stay connected. For instance, the death of a spouse is related to an increase in participation in group activities, frequency of contacting friends and family, and familial support . For disadvantaged older adults, the close social circle can be the only resource to cope with negative life events. However, for privileged older adults, there can be multiple alternative resources at their disposal. Thus, these adults have less frequent need to contact their close ties. The cultivation and maintenance of social ties in later life depends not only on socioeconomic background, but also on propulsive action that not everyone can take. However, to what extent personal effort counts in making and sustaining social connections needs to be further examined. It takes a considerable amount of time, material resources, and emotional labor to maintain and convert social capital to materialistic or emotional resources. Individuals from disadvantaged social backgrounds have a higher likelihood of experiencing instability in the social environment and are more vulnerable to negative changes . When pre-existing disadvantage and less favorable social context compound, the stress they place on the social networks of the disadvantaged is also aggregated. In the end, it can lead to the concentration of social disadvantage. This paper has a few limitations. First, this paper did not investigate the socioeconomic status of the network members of the older adults. Previous research suggests that older adults adjust networks in a way that favors their emotional needs over their materialistic needs. However, I propose that the way older adults utilize their network is highly likely to depend on their life situation and socioeconomic background. I mainly focus on the features of the ego and the contexts in which the ego is situated. I did not include any dyadic-level factors. Due to this limitation, I did not examine the network members' social resources. To understand how much the confidant network could help older adults in daily life, one needs to know what resources these network members provide for the older adults. Frequent contact could offer the emotional support that older adults need. Financial assistance is also a critical aspect of networks as resources. However, the NSHAP dataset does not have information on the degree to which the confidants provide financial aid for older adults. I also do not have data on the general material support that older adults obtained from their confidants. But previous studies based on empirical data have repeatedly shown that networks can provide various resources. Therefore, I assume this as a given. For future research, it would be helpful to collect data on what type of resources the ego obtains from each social tie. Second, this paper uses only three rounds of data across ten years to model change in network size and structure. That is to say, the survey may fail to capture changes in contextual factors and network features over short time scales. However, considering the size of the final sample, I still found significant association between the change in the social context and network features. Ideally, future research will benefit from more frequently collected longitudinal network data. Third, this paper only investigates the dynamics of older adults' close ties. It does not show how the weaker ties change as adults age. The pattern of change in social ties could be very different for the stronger ties and the weaker ties. Finally, due to the limitations of the data, the aspects of key explanatory variables and their change that I can include in the models are limited. Further research along these lines will help to improve our understanding of the relationship between various contextual factors and network dynamics. Page 10 of 11 were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. --- Author contributions N.F. wrote and revised this manuscript. --- --- Competing interests The authors declare no competing interests. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author and the source, provide a link to the Creative Commons licence, and indicate if changes Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

To what degree do social disadvantage and contextual factors matter for network dynamics in later life? This paper answers these two questions based on egocentric network data of older adults over a ten-year period. Specifically, I use longitudinal and nationally representative data on 1,168 older adults from the National Social Life, Health, and Aging Project. I use between-within models to separate the within-and between-individual effects of sociodemographic characteristics and contextual factors on three aspects of social connectedness in later life: network size, frequency of contact, and proportion of kin. Patterns of network change vary among people of different races and ethnicities as well as educational levels. Black and Hispanic respondents have a significantly smaller network size and a higher average frequency of contact with confidants. Moreover, Hispanic respondents have a higher proportion of kin in the network, compared to White respondents. Similarly, older adults with less education have a smaller network size, higher frequency of contact and higher proportion of kin in their confidant networks compared to those who attended college. Older adults who have better mental health are more likely to have a higher frequency of contact and higher proportion of kin. When an older adult starts to work for pay, their frequency of contact with confidants tends to increase. Older adults living in neighborhoods with stronger social ties are more likely to have a larger network size, higher frequency of contact, and lower proportion of kin in their confidant network. The above results show that disadvantaged backgrounds and contextual factors are associated with certain less favorable network characteristics, which helps to explain the concentration of social disadvantage on certain populations.

HAS THE RACIAL/ETHNIC DIGITAL DIVIDE AMONG OLDER COMMUNITY DWELLERS DEEPENED OR IMPROVED IN THE 2010S? Xiayu Chen 1 , J. Zak Peet 2 , Danan Gu 3 , and Kun Wang 4 , 1. University of Illinois at Champaign,Illinois,United States,2. Binghamton University,Binghamton,New York,United States,3. The United Nations,New York City,New York,United States,4. Binghamton University,State University of New York,Binghamton,New York,United States After the rapid societal and technological changes that occurred during the 2010s, it is unclear whether the racial/ ethnic digital divide has deepened or improved. Guided by critical race theory, this study aims to examine trends of the racial/ethnic effect on the first-and second-level digital divide and how race/ethnicity interacts with gender and education. Data from three rounds of the National Health and Ageing Trend Study were used in this study. Older community dwellers with normal cognition were included . The first-level digital divide was measured by Internet access. The second-level digital divide was measured by the usage of six online activities. Using weighted multiple logistic regressions, we found that race/ethnicity became not significantly associated with the first-level digital divide in 2019 but was consistently associated with the second-level divide. Neither gender nor education moderated the firstlevel digital divide association across the three years. For the second-level digital divide, education moderated the racial/ ethnic digital divide on online grocery shopping and banking in 2011 and 2015 but not in 2019; by contrast, education's moderation effects on buying prescriptions, contacting health providers, and getting health information online were significant in 2015 and 2019. No general trends were found for the moderation effect of gender on the second-level digital divide. Racial/ethnic gaps in the first-level but not the second-level digital divide were alleviated. More interventions should be provided for racial/ethnic minorities, especially those with low education. --- Jeffrey Stout, University of Central Florida, Orlando, Florida, United States Integrating assistive technologies into fall prevention interventions could improve health outcomes, but older adults in low-income settings face greater challenges with technology use due to factors such as cost, access, and location. We examined the acceptance of technology in low-income older adults and the factors associated with their acceptance. In this cross-sectional study, 126 adults aged 60 years and older agreed to participate in the study. Three technologies, including a BTrack balance system , bioimpedance measurement device , and activity monitoring device were used to assess fall risk. The Senior Technology Acceptance was used to assess the acceptance of technology. STA consists of four domains with 14 items . The Pearson correlation test was used to determine the correlation between STA scores, fall risk, and demographic factors. We found a significant correlation between STA and the CDC's STEADI fall risk score ; between STA and education ; and between STA and age . Participants had the highest mean STA scores to the lowest mean scores as follows: health conditions , control beliefs , attitudinal beliefs , and gerontological anxiety . The use of technology is acceptable to low-income older adults but fall risk, education, and age were associated with acceptance. They may benefit from technologically based fall prevention intervention since they have the potential to use technology with low fear expressed toward it. Abstract citation ID: igad104.2207 Lack of pharmacological agents to improve cognition has prompted research on behavioral interventions, such as cognitive training . CT benefit is inconsistent across non-patient populations. However, our recent work reveals multimodal commercialized CT shows promise for improving cognition and sleep in older adults with insomnia. Evaluation of non-commercialized CT allows for easy implementation of test scenarios/variables, monitoring and iterative optimization. This study: 1) created a novel non-commercialized CT for older adults with insomnia and 2) conducted usability testing/feature evaluation. COGMUSE is a computerized multimodal CT . Ten older adults with insomnia complaints completed 20 minutes of COGMUSE and the Game User Experience Satisfaction Scale . Open-ended feedback was solicited. Compiled transcripts were analyzed independently through deductive content analysis. Frequent topics/themes were identified. GUESS-18 average scores ranged from 3.5/7.0 to 5.9/7.0 for Star Snatcher, and from 3.1/7.0 to 5.5/7 for Worse for Wire. Feedback themes were largely positive . Negative themes included quick movement and lackluster graphics/gameplay "story" and lack of error consequences and practice trials . Older adults with insomnia evaluated COGMUSE as easy and enjoyable to use with acceptable aesthetics. Improvement themes largely focused on instructions and navigation. Next steps include updating COGMUSE and evaluating its preliminary efficacy on cognition and sleep. Over-the-counter medications with anticholinergic effects are widely used by older adults, despite their association with an increased risk of Alzheimer's disease and related dementias . Authoritative bodies, such as the American Geriatrics Society and National Academy of Medicine, recommend discouraging the use of both prescription and OTC anticholinergics. However, most interventions previously developed and tested have targeted only prescription anticholinergics despite the use rate of OTC anticholinergics being higher in older adult populations. Consumer-facing technology may be ideal for addressing OTC anticholinergic use as it is cost effective, scalable, and can address the constraints of relying on busy pharmacists to intervene during older adult OTC medication purchases; this has become especially relevant as pharmacies face staffing shortages, increasing pharmacist workload and requiring pharmacies adjust their hours of operation. Our interdisciplinary team of pharmacists, engineers, and designers engaged both older adults and pharmacy staff in the co-design of "OTC Senior Station": a user-centered, consumer-facing kiosk to be placed in community pharmacies to promote reduced anticholinergic use by older adults. Kiosk users are prompted to input brief information, which is used to present safer alternatives to OTC anticholinergics . This poster will present OTC Senior Station--what we believe to be the first consumer-facing technology to target OTC anticholinergic use-the participatory design methods used to create it, and the results of studies to assess its usability with older adults. --- MIXED-METHODS EVALUATION OF A NOVEL MULTIMODAL COGNITIVE TRAINING "COGMUSE" IN OLDER ADULTS WITH INSOMNIA

Subtle changes in instrumental activities of daily living (IADL), also termed everyday functional abilities, may be early markers of dementia. However, there are no widely available tools for tracking IADL function, and it is unclear whether such a tool would be used by older adults. The present study investigates older adults' adherence to a novel mobile app designed to conveniently and cost-effectively monitor IADL function. We also examine participants' acceptability of the app, including their overall satisfaction, perceived ease of use, benefits and limitations, and suggestions for improvement. Community-dwelling older adults (n=24; Mage=71.63 years) were randomly assigned three different simulated IADL tasks, to complete at specified times, each day for two weeks. Adherence was assessed using app usage data. App perceptions were assessed via survey and individual interview at the end of the two-week study period. Results indicate high adherence, with an average total task completion of 94.2%. Results from follow-up interviews revealed the app was generally perceived as "easy to use" and the assigned tasks could be completed quickly. Participants expressed frustration over app glitches that prevented them from successfully completing tasks and noted the assigned tasks and associated steps to complete were too simplified to be realistic. High adherence rates and general acceptance indicate the app's potential usefulness. Further research should assess long-term effectiveness and user experience, especially among a more diverse sample. If reliable and valid, such apps could enable early dementia detection, but only if their use is feasible and accepted.

are kept out of all important decision making processes, while the responsibilities ultimately impinge on them . They have no or very little power to take decisions due to many reasons like lack of education, lack of mobility, lack of control over resources, low level of awareness of their civic/ human rights, lack of credit facilities from the Government . The importance women's participation in family decision-making among third world countries is limited to some extent . The discriminatory social norms across societies, imbalanced gendered power within households and communities, unequal access to resources and opportunities impact on women's participation at all levels of decision making . The participation of women in decision making of major household purchases has a strong significant association with socio-background characteristics in outcome . There is a lack of confidence to contribute to public decision making of women prevents many women from trying to take on leadership roles in Myanmar . Women in Myanmar have a high burden of work, which includes both productive and reproductive work. Thus, the participation of Myanmar women in the development, implementation, monitoring, and evaluation of policies and programs can develop their qualities and leadership roles . Nowadays, it is often argued that women's contributions are undermined and their involvement in decision making is minimal. Information about women's extent of participation and decision-making power in livestock and household management is still lacking in Myanmar. There is no study and research about women's participation and activities in livestock management related to their decision-making behavior. Thus, the study was conducted to assess the factors affecting on rural women's participation level and decision-making behavior of rural women in livestock management and household activities. Specifically, the study aimed to: 1.1. Objectives Analyze the livelihood status, social norms and beliefs related to livestock production of rural women in study area. Assess rural women's participation level and decision-making behavior of rural women in livestock management and household activities. Explore the factors affecting on rural women's participation level and decision-making behavior of rural women in livestock management and household activities. --- Materials and Methods Livestock development is the driving force for rural development in Myanmar. According to Census in 2019, there are 112,891 populations of cattle, 70 populations of dairy cattle, 15,849 populations of sheep, and 29,455 populations of goats. Livestock is playing a crucial role in the fulfillment of basic subsistence requirements of the country's poor. The livestock farmers embark on various activities of livestock management like watering and feeding of animals, cleaning activities and milking . Women are the household managers, but their work is considered as non-productive, unorganized, undocumented and their contribution in agricultural labor force in developed countries is 36.7% while, it is about 43.6% in developing countries . As compared to men, contribution of women in livestock care and management is higher and they contribute 60 to 80% of labor in the animal husbandry . Women carry out their livestock production to their household commitments or duties, which include food preparation, child-care, water collection, gathering firewood, milling grains, cleaning, sewing and embroidery. The success of livestock enterprise relies heavily on effective involvement of women because they are closely involved in animal husbandry sort of activities . On the other side, male dominance in the decision-making of the household has continued in the gender biases of some areas even if women are the key providers of the labor perform the most of all . Male dominance and traditional belief system are the main factors which had affected the involvement of rural women in decision making process . Men are taking the lead role in the decision-making of their households . The reasons women are kept out of all important decision-making processes are due to lack of education, lack of mobility, lack of control over resources, low level of awareness of their human rights, and lack of credit facilities from the Government . --- Results --- Data Collection and Analysis The Number of households, about 60, were selected from three villages in Natmauk township, central dry zone area, Myanmar. A survey was collected quantitative, numbered data using ques-tionnaires or interviews and statistically analyze the data to describe trends about responses to questions and to test research questions or hypotheses. Interview using a structured questionnaire; key informant interviews; focus group discussions and desk review of relevant secondary documents were used in the study. Descriptive analysis and inferential statistics were used through the aid of the SPSS software for Chi-Square test with the use of Goodman and Kruskal's Lambda Coefficient correlation and stepwise regression methods to determine the relationship between the dependent and independent variables. --- Results and Discussion --- Demographic Factors Data of livelihood status, social norms and beliefs related to livestock production of the respondents were included in these factors. --- Age The mean age of the respondents was 51 years within the range of 17-73 years . Besides, the age of the respondents was categorized into three groups such as young, middle, and old. Most of the respondents are middle age group and they are between 38-64 years old. This was followed by the young group under 38 years, the old group64 years and above in the same percent , respectively. This finding is similar with the finding of Australian Center for International Agricultural Research , which described that the average age of the farmers in CDZ of Myanmar is 48.8 years. --- Educational Attainment Nearly about half of the respondents had no formal schooling, however, about 26% of them had primary level education and 20% had middle level education . More than 6% of the respondents had the monastic education. This finding agrees with the statement of Food and Agricultural Organizations and Yezin Agricultural University that most Myanmar people had in the primary education. On this regard, Myanmar Education Consortium reported that monastic education was the first education system of both men and women in Myanmar despite its chequered and politically sensitive history, it is still in demand today and currently provides education for 3% of school-aged children. --- Occupation All respondents are involved in livestock farming . However, respondents are cooperate-working in other jobs such as agricultural works , construction sites, standing as the hired labor, and selling in grocery. Respondents spent all their working time in the livestock activities of their houses including fodder cutting, watering, and feeding of animals, animal shed cleaning and milking as their main occupation. A few respondents said that they are grazing in pasture because they have enough food for their livestock. The National Consultative Committee also pointed that about 86% of the Myanmar people live in rural areas and are engaged in livestock farming. --- Land Holding of the Respondents There are three kinds of crop growing seasons in the study area: pre-monsoon, monsoon and post-monsoon. Thus, the respondents have different farm sizes in the three seasons . According to the data gathered, more than 56% of the respondents have 1-5 acres, while nearly 12%have 6-10 acres, and 1.7% have 16-20 acres in pre-monsoon, respectively. When it comes to monsoon season, 60% of the respondents have 1-5 acres followed by 3.4% of the respondents and 1.7% of the respondents have 6-10 acres and 16-30 acres, respectively. As to post-monsoon season, the respondents have 1-5 acres and 6-10 acres for 16.6% and 3.4%. When compared with the country's average rainfall level, CDZ receives limited rains and the farmers in this region are mostly grown in pre-monsoon and monsoon crops. In contrast, their farm sizes of pre-monsoon and monsoon are also higher than post-monsoon farm size and postmonsoon crops are lack of rainfall. According to the results of FGD, the respondents mostly cultivated their crops during pre-monsoon and monsoon because they got low profits for post-monsoon crops during lack of rainfall in the study area. Hein et al. pointed out that the main two farmland categories: lowland , and 'upland' for pre-monsoon, monsoon, and monsoon crops in the central dry zone, and he also described that the landholding of the intermediate farm households is within 1-5 acres. Majority of the respondents cultivated sesame and groundnut while some cultivated sorghum and Cotton in the pre-monsoon season as per in Table 3. A few respondents has pigeon peas during this season. Asian Development Bank approved that sesame and groundnuts are the two principal oilseeds produced commercially in the CDZ, Myanmar. When it comes to monsoon season, more than 55% of the respondent's cultivated sorghum and nearly 42% of them cultivated cotton. Besides, the rest of them are cultivated groundnut , rice , sesame , Chilli , pigeon pea and greengram . Naing approved that rice, sesame and groundnut are the most widely cultivated crops in central dry zone area during monsoon season. Results also show that most of the respondents cultivated cotton and chickpea at the same percent while others cultivated for sorghum and sunflower in post-monsoon areas. In this regard, Oxfarm also reported that the farmers in the dry zone are mostly grown cotton, pulses including chickpea and other oilseed crops including sunflower. According to JICA report of the central dry zone in 2010, the farmers in the dry zone area cultivated sorghum for the marginal cost effectiveness. --- Demographic Factors The ownership of livestock depends on a herd or flock size in the study area. According to the categorization of livestock guide in ACIAR research project in 2019, the livestock were categorized based on the lifespan and tercile analysis. In fact, the livestock were classified into two groups of young and adult for male and female in this study. Two years of male cattle were counted in adult and less than 2 years are in young male cattle. Likewise, one and half years of female cattle were counted in adult and less than one and half years are in young female cattle. Based on the terciles analysis, the 33rd, 66th and 100th percentiles were used to describe the herd/flock sizes . According to the data, the herds/flocks were classified into three sizes , corresponding to these terciles for each livestock species: cattle herds-small , medium and large ; small ruminants' flocks-small , medium and large . The respondents mostly had the small size of adult cattle male and female while the small size of young male group and female group is . Likewise, the medium size of adult cattle male and female is the same percent followed by the medium size of young male group and female group is . When it comes to the large size, the adult cattle male group and female group , however, the respondents have only young male group . This categorization results of cattle herd are agreed with the finding of Win et al. , that the number of animals kept per herd or flock was examined by terciles analysis, and the adult and young groups were categorized based on the life span in the central dry zone area. The small ruminants were also categorized based on their lifespan and ten months of male are added in adult group and less than ten months are in young male group. Likewise, eight months of the female small ruminants are added in adult group and less than eight months are in young female group. In the flock size of goat, the respondents have only the small young size of male and female . In terms of adult groups, the small size of male and female while the medium size of male and female groups has the same percent . There has only adult large size of female in the study. When it comes to the flock young sizes of sheep, the respondents have only the small size of male and female . In case of sheep flock adult sizes, they have the small size of male and female ; the medium size of male and female ; and the large size of male and female in this study. This is similar with the categorization of Win et al. in the small ruminants' flocks' size and life-span analysis. Key informant interviews revealed that the respondents used lifespan and tercile analysis to categorize their herd or flock sizes of livestock. --- Women's Participation in Decision-Making Behavior of Livestock Management and Household Activities As per Table 7, it was found that the breakdown of the gendered division of labor in terms of livestock chores. The respondents' participation in the livestock rearing activities was found in this table. Results show that women are responsible for performing livestock chores, especially around the house. A greater percentage of women feed livestock , provide water , care for young animals , clean shelters , care for sick animals and purchase forage , than men. This finding is agreed with the reports of Awan et al. , the participation of women in livestock management activities is higher than men's contribution in various livestock activities including clean livestock shelters, care for sick livestock, care for young animals etc. Cutting and carrying forage is a chore that is shared equally between men and women and for those households that own sheep. This finding agrees with Fischer et al. finding, that the forage chopping is the highest done with both husbands and wives in domestic groupings and male households are mostly found in chopping machine while female households are chopping with manual. Men are more influenced in decision making of sale of livestock , agricultural work for forage crops and take manure to fields for fertilizer than women. This finding is agreed with the results of Arshad et al. that about 74% of the male dominance has in decision making of livestock activities including sale of animals, fodder cultivation, sale of animals' produce to get useful. If shearing is performed by someone in the households, it is more likely to be a chore for women. The result was assumed that respondents are seldom to shear their sheep in this region. In the reports of WorkSafe New Zealand and National Centre for Farmer Health , which pointed that shearing and crutching are high-risk jobs that need a lot of manual effort workers, who shear or crutch thousands of sheep each year, can be at high risk of being injured. Data shows that both men and women seldom to collect the milk from their livestock and seldom to sell their livestock milk in this study because they used milk for their home consumption. van der Lee et al. approved that dairy milk is the source of livestock milk production and only 6% of dairy cattle milk production has in the central dry zone. This finding agrees with van der Lee's finding that the livestock farmers in the dry zone area seldom to collect their livestock milk and seldom to sell out them in the market. The domestic chores who actively performed in the household see in Table 8. Apart from agricultural work, where duties are predominantly performed by men or shared by men and women, women disproportionately bear the responsibility for performing all other domestic chores. Women are mostly involved in the four of five household chores such as clean house , wash clothes , cook for family and prepare donations for monks . This is agreed with the report of Alliance for Gender Inclusion in the Peace Process , which described that men are seen as responsible for hard-, productive-and outside work while women are seen as responsible for work taking place inside and domestic works. Although agricultural work is done jointly by men and women , men are also involved in this domestic chore. Result is similar to the findings of FAO and Singh and Srivastava , they stated that most agricultural activities are done jointly by men and women, in which, men are more involved in agricultural activities. Besides, they all spend their leisure time together with their friends and family . This finding is approved by the report of the United Nations Office for Project Services in Myanmar, in which, Myanmar farmers can spend their free time with their families todays because they get more free time due to changing mechanized farming. The gendered patterns of access to the resources required to care and manage livestock are seen in Table 9. Results indicate that women appear to have more access to the financial resources, that required to manage livestock than men based on access to household income to spend on expenses and access to credit either from formal institutions or friends and family . Razzaq et al. also approved that male and female respondents can manage their households' finances. But the animals and equipment are more likely to be owned by men or co-owned by both parties . The report of United Nations Women Watch Information and Resources on Gender Equality and Empowerment of Women explained that, in fact, women's lack of ownership over assets that can be used as collateral to leverage loans also constrains them more than men. Men have more access to traders and information about markets while women have access to traders and they got information about market when they want to buy or sell their livestock . In contrast, women have no opportunity to get traders and information to know about market in this study. This agrees with the findings of García that rural women in developing countries face difficulties to get information and difficulties in the process of negotiating prices with buyers and lack of mobility due to access to markets. The assessment results of FAO and WFP report also pointed that, farmers did not access traders, their crops will get low price with lower demand than usual. Men predominantly own cropping land but women have 16.7% of land as their own. This finding is agreed with the report of SasaKawa Global , that women have less access to land than men for a variety of legal and cultural reasons. Legislation has affirmed women's basic right to land but other customary practices and laws limit women's land rights in some cases. Some legislations restrict rural women in developing countries. Both men and women have access to communal grazing land . This means everyone has the right to graze livestock on a common pasture. The result is agreed with the report of Gilles and Jamtgaard , that most of the world's grazing lands is the publicly owned. --- Factors Affecting on Rural Women's Participation on Decision-Making Behavior in Livestock Management and Household Activities As per Table 10, the participation in decision making is a commonly used indicator of women's agency in the gender literature. It was found that women's decision-making behavior affected their domestic chores and livestock management activities in this table. Results from our study concur with evidence from other Asian countries, in which, women are often in control of the family finances . Half said that they make decisions on when to borrow money and many are either unilaterally or jointly involved in decisions on how to spend the money earned from selling livestock . While the tasks of feeding and caring for sick animals are the responsibility of women, men are more dominant in decision making on these matters including when to get medical treatment , when to sell/buy livestock and what to feed the livestock . However, a third of women stated that they unilaterally make decision on providing treatment to animals. Arshad et al. approved that caring for diseased and sick animals, was one of the main activities performed by rural women. Table 11 shows the important values and meanings for understanding women's motivations and purpose of their activities to encompass a range of different factors such as social and cultural beliefs and norms that guide behavior and to gauge religious and social values and norms for women's mobility that guide livestock rearing. While there is little evidence suggesting that women follow Buddhist norms of abstaining from killing animals and eating meat, livestock are commonly used to pay for donations to the Monastery for rituals . Mowe explained about Buddhist teachings on killing animals and abstaining from meat in Buddhist review of tricycle and Mon recommended that Myanmar farmers hold their donation festivals after harvesting their crops and selling livestock based on their rituals. In terms of mobility many women can go to the market but there is a spread in terms of limitations in mobility in and outside the village . It is also recommended that women frequently have poorer access to markets than men and play a limited role in the commercialization of livestock to sell out in market by themselves and livestock products in the management of livestock assets . Nearly half said they enjoy the social benefit of meeting friends to chat while taking animals grazing. This is agreed with the finding of Undeland that women graze animals jointly with the relatives and have no problems with access to good pastureland and water sources. Analysis of local values and meanings allows extension services to provide benefits to participants beyond income. --- Relationship of Variables To determine the relationship between the independent variables and the dependent variables of the women-headed households on the livestock rearing in the study area. Specifically, the non-parametric Chi-Square test with the Goodman and Kruskal's Lambda correlation coefficient was used to analyze the variations. Table 12 shows the significant and highly significant correlations between access to resources and decision-making descriptions of the women-headed households on the livestock rearing in this study. The ownership of land, information about markets, access to traders, and the information about livestock are highly significant correlated with time to buying or selling livestock, what to feed for livestock and when medical treatment. According to the results, the ownership of land is highly correlated with the decision making description of when to buy/sell livestock , what to feed and when medical treatment . It is approved in the report of Hernández-Jover et al. that ownership of livestock can take health records of animals and engage with the surveillance system for animals. The United Nations Development Programme recommended that if the farmers have their own land, they can be considerable capability in managing small scale livestock enterprises covering the whole livestock program and they also pointed that even some landless households have demonstrated considerable capability in managing small scale livestock enterprises. When it comes to access to information about market, it is highly correlated with when to buy sell and livestock and what to feed . This finding is similar with the finding of García , that access to market information can provide the information of suitable food and process of negotiating prices with buyers to know the exact time of selling and buying due to lack of mobility. Access to traders is highly correlated with when to buy and sell livestock , what to feed and how to spend money earned from livestock . In fact, the report of ACIAR, FAO and WFP and Win et al. explained that access to traders can support to access feed, to get veterinary services and inputs including when to buy and sell livestock and manage of their livestock income. Access to Information about livestock rearing practices is also highly correlated with when to buy sell and livestock and what to feed . UNDP pointed that access to information on livestock can be the extent of official livestock rearing processing and practicing and exports livestock and livestock products. Access to information from friends and family is highly correlated with when to buy/sell livestock and how to spend money earned from livestock . This finding is agreed with the report of Animal Welfare Institute , the livestock information sources and services such as the activities performed to facilitate any stage of the livestock life cycle information, that were available to farmers from their friends, family, neighbors, and co-workers and social media. García also approved that rural women in developing countries face the most challenges in financial resources due to a lack of information. --- Multiple Regression Analysis Multiple Regression Analysis the statistical findings of Spearman's rho correlation not only established the relationship between women households' livestock activities, access to resources, and decision-making discretion in the study area but also identified the possible predictors for the multiple regression analysis. Multiple regression analysis was used to further streamline the predictors of decision-making discretion to guide the researcher in formulating the recommended appropriate livestock management practices to access the better resources. The prediction formula of multiple regression analysis is: Y = β0 + β1X1 + β2X2 +----+ βkXk X = Independent variables Y = Dependent variables a = Y-axis intercept β = regression coefficient k = number of predictor variables Stepwise regression method was used to ensure the significant predictors remain after iterative model building using the set of predictors as variables. The predictors are the women households' livestock activities and their accessing resources that have strong significance with their decisionmaking discretions. Those predictors that have p-values less than the significance level of 0.05 and less than highly significant level 0.01 have statistically significant impacts. The multiple regression analysis results in Table 13 reflect that care for young animals , livestock feeding , livestock buying , livestock selling , caring for sick livestock , sheep shearing , cutting and carrying forage for livestock of women households' livestock farming practices, and access to income , access to credit either from institutions/friends/family , livestock ownership , livestock shelters or equipment ownership , access to a local trader , access information from friends and family , access information about market of the resources, will have the highest impact on decision making discretion of livestock farming. Table 13. Regression analysis of women households' decision-making discretion, their activities and access to resources. Not taking these predictors altogether will not have the expected high impact on improving the women's participation and their decision-making behavior in the study area. In essence, it points out that the participation of women in livestock farming practices and their access to resources in livestock management will have the highest impact on their decision-making discretions in this area. --- Model The results imply that women's participation in livestock farming and their decision-making discretion could clearly improve the activities in caring young and sick animals, livestock feeding, livestock buying and selling, sheep shearing, cutting, and carrying forage for livestock. Ahmad , Arshad et al. and Fischer et al. approved that women are actively involved in animal husbandry sort of activities including livestock feeding and caring, watering, fodder cutting, milking and animal shed cleaning etc. Result also shows that some products of livestock are commercialized when the benefits can be switched to women. Furthermore, FAO also mentioned that women-headed households are responsible to large and small animals marketing including by-products in practical, but they need the decision-making power over sale of livestock. The result shows women can be more actively participate and they can make the good decisions to access income if they access resources of credit, trader, market information and information from friends and families. FAO agreed that access to good market, access to credit, the high status and education, the high levels of customary practices can support women in the decision-making power over rural assets. Additionally, Win et al. , andFAO andWFP highlighted that access to traders can be benefit in getting animal feed, veterinary services, time to sale of livestock, and manage of their livestock income. On the other side, shearing is performed by one of the household members and it is more likely to be a chore for women. Result shows that the respondents seldom to shear their sheep in this region. WorkSafe New Zealand and National Centre for Farmer Health pointed out that shearing and crutching are high-risk jobs that need a lot of manual effort contractors who shear or crutch thousands of sheep each year can be at high risk of being injured. According to the results, the respondents need to be the owners in their livestock farming to manage their livestock and livestock equipment. UNDP pointed out that the farmers with their own lands can manage small scale livestock enterprises covering the whole livestock program. --- Conclusions The role of women's participation becomes important not only in livestock management but also households' activities. Even the respondents are in the middle-aged, but they did not get the lead role in decision making due to lack of access to resources and poor education of no formal schooling. Almost 60% of the respondents are small-sized farmers with the average household size is 4.6 and they mostly grow sesame, groundnut, and other tropical crops. The respondents mostly rear small sizes of adult cattle male and they categorized their livestock based on the tercile analysis and lifespan of livestock. Besides, the respondents serve as the good housewives with domestic chores. In case, men households are chief of the decision makers in the households because they access to resources more than women's households, however, access to financial resources and household income to spend on expenses are stronger on the women. Access to resources contributed substantially to the decision-making descriptions of the households. The respondents also need to be the owners in their livestock farming to manage their livestock and livestock equipment. The information got especially from friends, family and traders are helpful in buying/selling livestock, spending money earned from livestock, taking medical treatment of the livestock, and feeding the food for the livestock. In fact, women can be more actively participate and they can make the good decisions to access income if they access resources of credit, trader, market information and information from friends and families. This implies that the higher access to resources, the decision making will be more prominent. Thus, women can improve their decision-making in livestock activities for the household by empowering women in livestock farming. Since the correlation and multiple regression analyses were able to identify and streamline women activities that need to be focused on so that to make good decisions in livestock farming, this should be taken as a concrete guide for the involved villages, their officials, the Government of Myanmar, and all project implementers to follow. For longer-term outlook, participation of women and access to resources are important to achieving decision making behavior in livestock farming. In addition, providing the necessary resources to women in livestock farming, they can easily facilitate their livestock activities and their performance will be improved. Policy makers have to consider these constraints identified in this study to provide the necessary resources to women in livestock farming, to train women as the female leaders in their households and to develop guidelines for sustainable livestock production not only in the central dry zone but also the whole country. The gender-based equal opportunity can be initiative through a policy to enhance the participation of women and achieve development of women decision-making behaviors at the national scale. --- CRediT Author --- Data Availability Statement: Not applicable. Funding: This research was funded by the Australian Centre for International Agricultural Research under Project Developing Market Oriented Small Ruminant Production Systems in Myanmar . --- --- Farming experiences. 1. Crop production --------------------yrs 2. Livestock production ---------------------------yrs Access information about markets when they want to buy or sell livestock? Owns the land that crops are grown on? Access to communal grazing land when they need? Constraints -decision making. --- Activities Decision made by Family member Men Women Both When to buy/sell livestock? How to spend the money earned from livestock? What to feed/graze the livestock? When to get medical treatment for livestock? When to seek medical treatment for family? How to educate children? How to manage household finances? When to borrow money? How to organize the marriage of children?

The study aimed to assess the factors affecting on women's participation level and decision-making behavior of rural women in livestock management and household activities in particularly 60 randomized respondents from three villages of Natmauk township, central dry zone area, Myanmar. Descriptive analysis, Chi-Square test and stepwise regression methods were applied to analyze the relationship of women's participation and decision-making behavior of respondents. Results of the KII and FGD were used to further explains in survey. Respondents are middle-aged group, small-sized farmers, busy with domestic chores and had no formal schooling. They mostly grow sesame, groundnut and other tropical crops and rear small sizes of adult cattle males in the study. Men are chief decision makers in their households because they have access to more resources. Ownership of land and access to information is highly affected on decision making of when to buy/sell livestock, what to feed and when medical treatment of livestock. Information got especially from friends, family and traders are helpful in the decision making of buying/selling livestock, spending money earned from livestock and feeding the food for the livestock. Spearman's rho correlation was used to identify and streamline women's activities that need to be focused on so that to make good decisions in livestock farming.

INTRODUCTION Generation Z refers to people born between the mid-1990's and 2009, who grew up with the digital society and view digital technologies as the foundation of their lives . Gen-Z belongs to a larger social media user population that has been conceptualized as the digital natives . Digital natives were born and raised in the digital age, and they spend most of their lives surrounded by and using computers, video games, cell phones, and all the other toys and tools of the digital age . While the rationality of the conceptualization of digital natives is still in debate, a growing number of research has indicated that the younger generations significantly differ from their predecessors in terms of technology-related perceptions, motivations, and behaviors . China has ∼300 million Gen-Z and 30 million Gen-Alpha Internet users, constituting 1/3 of China's Internet user population . Most of China's internet users are also social media users, and about 1/4 of them spend more than 4 h/day on WeChat, one of China's most popular social media . Previous studies have discussed from multiple perspectives the predictors, characteristics, mechanisms, and consequences of the social media-user interactions in China . However, what has been relatively understudied is the extent to which Chinese Gen-Zs' social media habitus are associated with their characteristics as being digital natives, as well as how their social media engagements are associated with digital social inequalities . In this study, therefore, the main objective is to fill these gaps by examining the characteristics of and differences in social media habitus among Chinese Gen-Z users, as well as exploring how their social media uses and gratifications are associated with economic capital using the Bourdieusian approach . --- LITERATURE REVIEW One influential theoretical framework to approach the social media-user interactions is the uses and gratifications theory , which highlights the importance of individuals' social and psychological needs in shaping their motivations and, consequently, their communicative behaviors . On one hand, previous studies indicated that Gen-Zs differ from their predecessors in many aspects of online motivations, such as being more desired for self-expressing and self-disclosing, online shopping, online enjoyment, memetic engagements, content-generating, and sustainable online behaviors . On the other hand, the extent to which social media uses can satisfy Gen-Zs' online motivations depends on their affordances. Social media affordances keep evolving with the development of the technologies and the industry, shifting from a focus on networked communication to the scope of online sociality . There have been discussions on how socialization, as a pivotal social media affordance, plays an important role in satisfying some of Gen-Zs' online motivations . In this study, we will contribute to the discussions by exploring how Gen-Zs' social media uses, including both socialization and beyond, connect with their online motivations in the Chinese context. Therefore, we propose our first research question. RQ 1 : What are the relationships between Chinese Gen-Zs' online motivations and social media uses? Previous studies indicated that individuals' technological engagements are associated with inequalities in their social, economic, and cultural status and life opportunities . In light of the limitations of a functionalist perspective to studying digital social inequalities, scholars introduced the Bourdieusian approach that views technological engagements as occurring in social spaces made up of interrelated fields constraining and shaping each other, with distinctive user habitus and capital . According to Bourdieu ), habitus is a set of dispositions that structures individuals' practices, and capital refers to socially valued assets that can influence individuals' status in the system through accumulating and exchanging. The conceptualizations of habitus and capital contribute to deepened understandings of Gen-Zs' social media uses and gratifications. Social media habitus serves as an embodiment of the interactions between Gen-Zs and their situated socioeconomic context, and it shapes and repeatedly magnifies user disparities in social media practices through machine learning and algorithms . Capital is another key to understanding the predictors and consequences of Gen-Zs' social media practices . Previous research showed significant correlations between economic capital and technology-related habitus, which further connect with digital social inequalities . As for Gen-Z, there is still insufficient knowledge to unpack how the youth from low-and upper-mid-income families would differ in terms of their preference of social media practices, and how economic capital can moderate their social media uses and gratifications. Hence, we propose the second and third research questions. RQ 2 : What are the differences in social media practices between Gen-Zs from low-and upper-mid-income families? RQ 3 : How does economic capital moderate Gen-Zs' social media uses and gratifications? --- METHODS --- Procedures and Participants This study employed an online survey for data collection. The questionnaire was adapted from literature and revised based on several pilot studies . Participants were students from a large public university in Southwestern China. Participants consisted of 221 Chinese Gen-Z social media users , and aged between 20 and 24 . Annual family income was coded as low and upper-mid using 50,001-100,000 as the threshold . --- Measurements --- Online Motivations Ten items were adapted from literature , and were measured on a 5-point Likert scale . A principal component factor analysis identified two dimensions of the motivations . Daily routine alternatives were motivations regarding gaining information , entertainment , online shopping , and doing school-and work-related things ; socialization included seeking help , sharing with others , developing/maintaining relationships , and self-promotion . --- Social Media Use Nineteen items measured how frequent participants engaged in social media activities. A principal component factor analysis constructed four dimensions : networked communication included checking updates , liking/commenting , communicating with others , and checking group-discussion records ; social capital accumulating and exchanging included asking for help , supporting others , self-promotion , and obtaining self-beneficial information ; self-expression included posting updates , sharing selfies , and selfexpressing ; news watching included watching news via social media . --- Demographics Participants' age, gender, education background, urbanness, and annual family income were collected. --- RESULTS For RQ 1 , we used SEM to explore the relationships between Gen-Zs' online motivations and social media uses, with demographics as covariates. A bootstrapping technique with 5,000 replicates was performed to achieve generalizability beyond the sample. Results indicated that the daily routine alternatives motivation significantly predicted NC and NW, and the socialization motivation was associated with SCAE and SE on social media . For RQ 2 , significant differences in social media practices were observed between low-and upper-mid-income families, when controlling for age, gender, and education background. Gen-Zs from upper-mid-income families used social media for more NC [F = 17.78, p < 0.001] and NW [F = 5.01, p < 0.05] than those from low-income families, whereas two groups did not significantly differ in SCAE and SE on social media. Regarding, RQ 3 , several hierarchical regressions were conducted. For Gen-Zs with the daily routine alternatives motivation, income significantly moderated NC, B = -0.23, β = -1.12, t = -2.67, p < 0.01. For those driven by the socialization motivation, income significantly moderated SCAE and SE . We used Dawson and Richter's approach to probe the interaction effects. As daily routine alternatives motivation became stronger, the low-income participants had a greater increase of their NC on social media than those with uppermid-income . When socialization motivation was low, Gen-Zs with more economic capital showed less SCAE and SE than those from low-income families; whereas when the richer were strongly motivated to socialize online, they would surpass the poorer in both social media practices . --- DISCUSSION Results indicated that Chinese Gen-Zs have different social media uses depending on two categories of online motivations: social media as communicative tools and news portals when they are doing their daily routines online; and as platforms for social capital accumulating and exchanging and self-expression during online socialization. The findings are consistent with and extending literature on characteristics of digital natives and indicate different social media uses based on different scenarios. Furthermore, compared to other U&G studies on social media usage , our results highlighted an emphasis on social capital throughout social media uses and gratifications, and the integration of social media into daily routines by Chinese Gen-Zs. Another contribution of this study is that we employed Bourdieusian approach to explore how economic capital influences Gen-Zs' social media uses and gratifications. We observed distinct social media habitus between Gen-Zs from low-and upper-mid-income families: the latter embrace a more instrumental-rational habitus to use social media more frequently as a communicative tool; whereas the former value the importance of online socialization to increase their social capital, but have no more practices in related social media activities. Finally, Gen-Zs from upper-mid-income families take a more conservative stance in SCAE and SE when their socialization motivation is low. This finding is consistent with the literature that a higher income is not necessarily associated with more frequent social media practices. --- CONCLUSION In this study, we examined Chinese Gen-Zs' social media uses and gratifications and found: daily routine alternatives motivation predicts NC and NW, and socialization motivation is associated with SCAE and SE; Gen-Zs from upper-midincome families employ a more instrumental-rational habitus to use social media as a communicative tool than those from low-income families; Gen-Zs with higher economic capital tend to be more conservative in SCAE and SE when socialization motivation is low. Applying the Bourdieusian approach to U&G studies, this study highlighted the importance of economic capital in Gen-Z's social media practices: it helps formulate distinct social media habitus that may be repeatedly consolidated by machine learning and algorithms, as well as influences social capital accumulating and exchanging; both may lead to more digital social inequalities among Gen-Zs. Despite the limitations , our findings shed light on future studies on connections between economic capital, social media U&G, and digital social inequalities among and across digital generations. --- DATA AVAILABILITY STATEMENT The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- --- Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. 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This study aims at contributing to literature by investigating characteristics of Generation Z's social media uses and gratifications and the moderation effect of economic capital. Specifically, we employed online survey as the main research method to examine the connections between the young generation cohort's online motivations, social media practices, and economic capital. A total of 221 Chinese Generation Z social media users were recruited in the survey. Results indicated that (1) Generation Zs have different social media engagements depending on whether they were connected for daily routine alternatives or socialization; (2) the young cohorts from upper-mid-income families demonstrated a more instrumental-rational habitus to use social media more frequently as a communicative tool than those from low-income families; and (3) motivations and family income interacted to influence Generation Z's social media practices (e.g., social capital accumulating and exchanging and self-expression). Findings here provide empirical reference to deepened understandings of the interactions between social media and digital generations, and their connections with digital social inequalities.

Introduction Muhammadiyah as a religious social organization has a social responsibility to manage changes in society productively and progressively . The work of Muhammadiyah Branch Kadirojo and Aisyiyah Branch West Palbapang has been very deep and deep-rooted. However, there has begun to be a stagnation of community participation in following the pace of change managed by Muhammadiyah lately . There was something quite disturbing lately about the existence of Muhammadiyah and Aisyiyah in the village of Kadirojo Palbapang Bantul. First, a number of members or sympathizers of Muhammadiyah and Aisyiyah began to feel reluctant to attend a number of routine activities such as recitation which is carried out both weekly and monthly. When conducted a personal search, a number of members stated that they were uncomfortable attending the activity because they were unable to provide infaq in all Muhammadiyah activities. This is closely related to the social contraction after the Covid19 pandemic which caused a number of shocks to the pillars of public welfare . Moreover, Muhammadiyah and Aisyiyah studies discussed more about the morals of life in the end times compared to studies with material about managing the world productively, competitively and islamically. Studies that provide soft-skills and hard-skills seem to have not received an adequate portion. Second, the presence of joyful activities at the Muhammadiyah Congress in November 2022 had a considerable bitterness. This is related to the failure of PRM Kadirojo and PRA Palabapang Barat to depart by bus together. The number of PRM and PRA members in Kadirojo and West Palbapang is actually quite large to be able to rent 2-3 buses with a passenger capacity of 50. However, in the program to become cheerleaders for the Muhammadiyah Congress, the group could not leave because the number of Muhammadiyah members and sympathizers who wanted to leave by bus did not meet the quota of just one bus. Finally, a number of PRM and PRA administrators used their own modes of transportation. After being traced, it is undeniable that there was a relatively large financing factor to be a happy congress where each participant was charged around Rp. 100,000-Rp. 150,000. This condition was considered quite burdensome in the midst of agricultural problems in the Palbapang Bantul area in the last 5 months because no suitable planting activities have been carried out so that practically a number of members and sympathizers of Muhammadiyah and Aisyiyah did not have adequate income. This condition provoked PRM Kadirojo and PRA Palbapang Barat to address the issue of Islamic teachings based on ghairu madhlah or muamallah duniawiyyah to get a larger portion. A study conducted by Menchik showed that Muhammadiyah must be able to answer the dynamics of social, economic and political problems in society . A number of studies from Roasyadi also showed that a number of Muhammadiyah universities have developed programs on the formation of young entrepreneurs as a form of Muhammadiyah's responsibility to contribute to the institutionalization of community welfare . The activity base of PRM Kadirojo and PRA Palbapang Barat in 3 mosques, namely Al-Fajar, Istijabah and Sayyidah Qawwiyah will be the central point in the economic development of the Ummah. Studies from Rambe have shown that mosques can play an important role in building the economy of Muhammadiyah . In the assessment conducted together with PRA Palbapang Barat, there was a problem of discomfort to follow activities in Aisyiyah which were routinely carried out both weekly and monthly periods because they tended to be mobilized to provide the best infaq when present in a number of recitations. Aisyiyah's activity platform based on ansich religious studies has made the situation uncomfortable so that a number of variations of Aisyiyah's activities are needed in the form of increasing productive economic capacity by utilizing a number of social capital owned by the community such as large agricultural land around the house, and the potential availability of planting media made of both humus and livestock manure . Second, problems were related to the bad experience of caring for Aglonema ornamental plants and Aroids that are easily dead, rotten or stunted so it is not attractive to look at and has no economic value. This includes the lack of knowledge of Aisyiyah members on Aglonema and Aroids plant species that have high economic value . So far, only a million Aglonema plants such as Donacarmen and Big Roy are known which have ordinary economic value. Variants such as Moonlight, Emerad, Sultan of Brunei, Tiara, Cunkwok, and Golden Hope which worth tens of millions are relatively unknown . In addition, the Aroids variant which has a variegate pattern is also not widely known . This knowledge would be shared with the audience. Third, the problem was the marketing the products produced. It is undeniable that selling ornamental plant products is perceived as a type of sale that requires certain expertise. This is related to the need for ornamental plants which is still at the level of tertiary need, so the knowledge of the marketing map is new. This includes marketing using digital platforms such as Marketplaces on today's social media such as Instagram, Tiktok and Facebook. --- Methodology The method of implementing this service activity took 3 major steps. First, conducting FGD to build new awareness that being active in the Muhammadiyah organization will get benefits in the world such as social, economic, cultural, and benefits in the end such as getting the paradise that Allah has promised. Muhammadiyah is not an organization that will reduce the social capital of its members and sympathizers, but rather facilitates the social benefits of capital to be more useful. Second, training in the management of household industries based on Aglonema and Aroids ornamental plant agriculture which have a high investment value. Training in the context of hands-on practice from how to chop and separate the mother of houseplants to the preparation of ornamental plant-friendly planting media by utilizing the resources available in the community such as humus from bamboo leaves, cocopeat from coconut husk, rice husks, and manure from cow, goat, rabbit and chicken dung. Third, training in marketing ornamental plants on social media platforms, both for marketing at the domestic level, and export opportunities for consumers abroad. This is because the domestic and international market segments regarding the need and availability of unique ornamental plants are still broad . Evaluation of this method would be measured from pre-test and post-test instruments, whether there is an increase in knowledge, attitudes and behavior of the audience after the community service intervention process. Is there an increase in awareness of Muhammadiyah participation or does it just stop at the level of knowledge of ornamental plant management? --- Results and Discussion In the view of the community, there is a stigma that being a Muhammadiyah activist means giving up time, property and soul to fight in the path of Allah. To be Muhammadiyah will be very noble if the person is finished with the problems of social, economic and cultural life, so that he can fully devote himself to the struggle of Muhammadiyah in upholding the religion of Islam. This view seems to emphasize that people who are not finished with themselves in the context of world affairs when participating in Muhammadiyah will be a burden to Muhammadiyah, and instead of becoming a burden it is better to stay away from Muhammadiyah. This condition was also confirmed in a number of studies in forums organized by a number of mosques affiliated to Muhammadiyah around the Palbapang community. Actually, in Muhammadiyah, there are a number of Islamic forums that have very diverse tasks, principals, and functions from Majlis Tarjih, Tabligh council, education, health, and economy. However, at the village level, the Majlis that has the most routine activities is the tabligh council which is then the main base of activities to hold recitations. Other councils are more widely known by Muhammadiyah activists, or who are administrators at the Branch, Regional, Regional and Central levels. For Muhammadiyah sympathizers, Muhammadiyah's activities are in the form of recitation, education, and health services. This devotion shows the sympathizers of Muhammadiyah and Aisyiyah that Muhammadiyah and Aisyiyah have an Economic Council, which pays strong attention to how to empower all Muslims, and humanity to become an independent society and not become a weak society. The context of Aroids and Aglaonema empowerment has a strong momentum in Palbapang village, so that after discussion at the branch level, there is enthusiasm to join and get to know Muhammadiyah more closely. This program received more response than the Economic Council program which offers training in making decorative objects, batik, and Ecoprint or making batik using natural materials. Why are Muhammadiyah and Aisyiyah sympathizers interested? From the FGD, it was found that the Covid19 pandemic has made gardening activities a favorite, fun, refreshing activity and has the potential to increase income. In popular terms, gardening is part of an effort to multiply the oxygen space located. Gardening means giving alms of oxygen, while earning additional income . Very different from popular activities during the Covid19 pandemic such as cycling, a fun activity , but it actually consumes oxygen, is expensive, and does not have an impact on increasing income. Second, gardening activities for villagers are actually an observed daily activity. So far, the residents have undergone farming from generation to generation, meaning that basic knowledge about gardening from planting, caring, fertilizing, propagating, and harvesting is something that has been lived every day . However, some people do not have much knowledge about how to get good seeds competitively, and how to market productively. Third, aglaonema and Aroid are unique plants a variety of types that continue to grow rapidly, along with many breeders who produce beautiful and exotic plant variants. Aglaonema as ornamental plants also has a relatively high price compared to traditional ornamental plants, where both have become global plants, and are also marketed globally. This plant in its form is relatively small, so it can be placed in the corner of the house exotically and pleasant to the eye . --- Figure 1. Community service activity From the implementation of pre-test and post-test regarding gardening procedures, there was relatively little change in knowledge, where the increase in knowledge was more about how to make the right planting media. This is closely related to planting material for farmers as the basic knowledge farmers carry out daily. The knowledge that increased significantly was the knowledge about online marketing, where the participants previously did not know much about buying and selling plants through Facebook, Instagram, Tik Tok or Youtube. For most participants, social media was a space of expression to vent or watch a number of entertainments from music, films to religious lectures. After the service activities were carried out, there was a change in the mindset of the residents of Kadirojo, Palbapang that being active in Muhammadiyah and Aisyiyah are not only saving rewards in the last day by reducing their social capital, but also getting progress information needed by the community. It can share information, access, capital to strengthen each other. This view is reflected in the testimony of the participants that inclusive-based empowerment allows the participants to get equal treatment and distribution of social capital, and provides direct benefits. --- Conclusions Service for the community is a part of social organization advocacy to the needs of the community. Social organizations that cannot provide proper advocacy space to the community will be increasingly alienated, and will eventually be abandoned by the community itself. Critical awareness began to be realized by Muhammadiyah and Aisyiyah regarding the need to accelerate the Majlis within Muhammadiyah to move and serve the community proactively. An inclusive and objective program will be able to mobilize public awareness that being part of Muhammadiyah and Aisyiyah are a matter of mercy and grace. The empowerment of Aisyiyah activists through the selection of programs that are in accordance with the needs of the community has a positive impact on making the participants to be active in the organization where the Aisyiyah organization is perceived by the community as an organization that continues to pay attention to social and economic problems faced by the community. Diversification of community empowerment has a positive impact on community participation in Muhammadiyah engagement. Empowerment that touches the substance of the problems faced by the community will increase the positive image of Muhammadiyah which always develops social capital for esmpathy and sympathy. Empowerment programs that have a domain at the family level but have an impact on equality in the family environment and are able to give socio-economic impacts on families are programs that are in great demand for women.

This article explains about the assistance given for the Aisyiyah Branch in stimulating women in doing "shaleh" charity in the Muhammadiyah company through the Aisyiyah organization through empowering the economic sector. It is related to the emergence of saturation in some women's communities towards Aisyiyah's routine activities which contain recitation activities and motivation to perform shadaqah and infaq. This pattern builds character that to become a member of Muhammadiyah and Aisyiyah, one must be a well-off person. To change this trend, this community service has developed the local wisdom of the women community in Kadirojo with a productive social and economic approach in the field of ornamental plants as a new trend of gardening in modern society. The methods carried out are cultural training of Aglaonema and Monstera ornamental plants as types of ornamental plants that have high economic value, and product marketing training in the marketplace. The results showed that Muhammadiyah's program run towards increasing the social and economic capacity of the community will increase the community engagement to actively participate in Muhammadiyah.

Introduction Globally, many people have faced challenges during the COVID-19 pandemic including loss of income and employment, worsened mental health, and decreased access to medical care [1,2]. The pandemic has also amplified the intersectional vulnerabilities faced by many people living with human immunodeficiency virus . For example, among people living with HIV in the United States, African-Americans and those with low incomes were more likely to suffer complications following severe COVID-19 infection [3]. People living with HIV may also have difficulty placing trust in the health care system; in one cohort of African-American people living with HIV in the United States, 97% of individuals endorsed at least one COVID-19 mistrust belief and half had COVID-19 vaccine-specific mistrust [4]. By contrast, people living with HIV may be more engaged in COVID-19 preventative behaviours or vaccine uptake than the general population [5,6]. People living with HIV have known history of activism and high level of community involvement in research. Considering this, more study of COVID-19 preventative behaviours is needed within the population of people living with HIV that can guide new policies and enhance vaccination success. Since the first global COVID-19 immunization campaign was launched, attitudes and uptake of the COVID-19 vaccine in people living with HIV have been much more extensively researched than behavioural practices . In this study, we sought to understand the relationships between preventative behaviours and COVID-19 infection in a multi-centre, cross-sectional study of people living with HIV in Canada. We addressed this topic through four questions: Does previous known COVID-19 infection influence preventative behaviours among PLWH? Is participant multimorbidity associated with preventative behaviour practices among PLWH? Are preventative behaviour practices, living in a crowded space, and working in close proximity to others associated with COVID-19 transmission among PLWH? Are preventative behaviour practices and/or uptake of COVID-19 vaccination associated with developing symptomatic COVID-19 infection during the highly contagious Omicron wave among PLWH? --- Methods Our study population comprised people living with HIV living in Montréal, Ottawa, From the total study population, responses from appropriate subsets of participants were analyzed to address each of the four aforementioned questions, as described in Table 1. Statistical analysis was performed to assess for significant differences between demographics and CITF questionnaire responses with t-test, chi-square test, and Fisher exact test used as appropriate. Multivariable logistic regression was performed to assess for associations between outcomes and predictors of interest while accounting for other factors that might confound the association based on prior knowledge. No imputation was performed to impute the missing data as this is mainly a descriptive study. Conduct of this study was approved by the Canadian Institutes of Health Research Canadian HIV Trials Network Scientific Review Committee and Community Advisory Committee, as well as by each site's Research Ethics Board as previously outlined [7]. and laboratory testing . Of note, the vaccine immunogenicity study is still ongoing so the total number of COVID-19 infections during the total study period is currently unknown. Overall, preventative behaviours were frequently practiced in the cohort, with 87% masking in public, 79% distancing, 70% avoiding large gatherings, and 65% limiting contact with vulnerable persons. --- Does previous known COVID-19 infection influence preventative behaviours? To address this question, we excluded individuals with positive serum COVID-19 antibody testing but no knowledge of prior infection . A detailed explanation of the participant subsets used in each of the four questions is found in Fig. 1. Participants reporting prior known COVID-19 infection were more likely to identify as nonwhite , less likely to have stable HIV infection , have more household members , fewer household bedrooms and bathrooms per person , and were more likely to be employed in health care than those not reporting prior infection. There were no significant differences in the other demographic factors between the prior known infection and non-infected groups. In response to the preventative behaviours survey, participants with prior known COVID-19 were more likely to self-quarantine when thought to have been exposed to COVID-19 but were not symptomatic and selfisolate when thought to been infected with COVID-19 . These differences remained statistically significant after adjusting for age, sex and the aforementioned patient characteristics that were different between groups . These were the only significant differences in preventative behaviours between groups. --- Is participant multimorbidity associated with preventative behaviour practices? Participants in the multimorbidity group were more likely to be older , live in a household with fewer members , have more bedrooms and bathrooms in the household per person , usually get an influenza immunization , and less likely to be performing paid or unpaid work in close physical proximity to others . They were more likely to be vaccinated with four doses against COVID-19 by September 2022 . In response to the preventative behaviours survey, participants in the multimorbidity group were more likely to be practicing physical distancing . This difference, however, was no longer statistically significant after adjusting for participant characteristics , and no other significant differences in preventative behaviours between groups were noted. --- Are preventative behaviour practices, living in a crowded space, and working in close proximity to others associated with COVID-19 infection? The participants in the COVID-19 infection group were more likely to have fewer bedrooms per person . There were no identified differences in the proportion of participants performing paid or unpaid work in close physical proximity to others between those with and without COVID-19 infection . There were no identified differences in preventative behavior practices between those with and without baseline COVID-19 infection. --- Are preventative behaviour practices and/or uptake of COVID-19 vaccination associated with developing symptomatic COVID-19 infection during the highly contagious Omicron wave? In Canada, the Omicron wave began in late November 2021 [9]. Participants in the Omicron infection group were more likely to have been tested for COVID-19 at some point before study enrolment (p = 0.015 --- Discussion Using data from our cohort of people living with HIV, we examined four questions regarding COVID-19 preventative behaviours. Another study done in the Canada in general population assessed determinants of adherence to major coronavirus preventive behaviours, including demographics, attitudes and concerns and showed that adherence to COVID-19 prevention behaviours was worse among men, younger adults, and workers, and deteriorated over time [10]. We did not observe these differences. Among those having prior known infection with COVID-19, the only difference noted in preventative behaviours was an increased likelihood of self-quarantining after a suspected exposure. Participants engaged in work with close physical proximity to others did not report different preventative behaviours or COVID-19 infection proportions. Multimorbidity was associated with more physical distancing, although there were also multiple demographic factors noted to be different in this group . In the highly contagious Omicron wave, we did not observe any differences in vaccine uptake or preventative behaviours between those who did and did not sustain infection. Overall, preventative behaviours were practiced in a high proportion of the cohort, with 87% masking in public, 79% distancing, 70% avoiding large gatherings, and 65% limiting contact with vulnerable persons. In a 2020 Canadian survey cohort of the general population, over 70% always reported masking in public and staying home when sick while over 50% avoided large gatherings; only 40% engaged in physical distancing [11]. Preventative behaviours including masking, physical distancing, and limiting gatherings have had high uptake globally in people living with HIV. In a South African cohort of people living with HIV, 80% changed one or more activities based on public health recommendations [12]. One United States cohort of 149 people living with HIV reported engaging in an average of 2.8 physical distancing behaviours [13]. In a cohort of 545 primarily male Indonesian people living with HIV, 70% reported practicing preventative behaviours [2]. Among 376 Rwandan people living with HIV, factors associated with the increased practice of preventative behaviours included duration of antiretroviral therapy and female gender [14]. Increasing age had a consistent association with preventative behaviours in one rapid review of the general population in developed countries, while health status and education did not show consistent effects [15]. Limited data exist on the effects of prior COVID-19 infection on preventative behaviours or on the influence of working in close physical proximity to others on COVID-19 behaviours in people living with HIV. Greater vaccine uptake among those with multimorbidity and/or older age has been reported in a South African cohort of people living with HIV [12]. In contrast, a Chinese cohort of people living with HIV was less likely to receive COVID-19 vaccination [16]. Fear of disclosure of HIV status at vaccination appointments was reported in this later assessment which may explain the heterogeneity of findings across reports. We observed no difference in vaccination status between participants sustaining Omicron infection and those not infected. We note that studies in the general population have shown a less protective effect of original vaccine formulations against the Omicron variants although behavioural differences during the Omicron wave may have also played a role in our cohort [17]. Our study has several limitations: the entire cohort was participating in COVID-19 vaccination programs to some degree and had easy access to provincial and federal public health programs for testing and education. This may limit the generalization of our results to settings where public health infrastructure is not available to disseminate information and vaccines. It also encapsulates behaviours for only a portion of people living with HIV who consented to vaccination. Data was collected only at the beginning of Omicron wave resulting in small number of participants being infected by COVID-19 Omicron variant and therefore may not be fully generalizable to Omicron and subsequent waves. In summary, our Canadian cohort of people living with HIV reported high rates of preventative behaviour practices. We found differences in preventative behaviours among those with prior COVID-19 infection and in those with multimorbidity suggesting these are key motivating factors in facilitating preventative behaviours. • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year --- • At BMC, research is always in progress. --- Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from: --- --- Abbreviations --- --- --- --- Competing interests The authors do not have other relevant employment or financial interests to disclose. ---

Few studies have examined preventative behaviour practices with respect to COVID-19 among people living with HIV (human immunodeficiency virus). Using a cross-sectional survey from a Canadian Institutes of Health Research Canadian HIV Trials Network study (CTN 328) of people living with HIV on vaccine immunogenicity, we examined the relationships between participant characteristics and behavioural practices intended to prevent COVID-19 infection. Participants living in four Canadian urban centers were enrolled between April 2021-January 2022, at which time they responded to a questionnaire on preventative behaviour practices. Questionnaire and clinical data were combined to explore relationships between preventive behaviours and (1) known COVID-19 infection pre-enrolment, (2) multimorbidity, (3) developing symptomatic COVID-19 infection, and (4) developing symptomatic COVID-19 infection during the Omicron wave. Among 375 participants, 49 had COVID-19 infection pre-enrolment and 88 post-enrolment. The proportion of participants reporting always engaging in preventative behaviours included 87% masking, 79% physical distancing, 70% limiting social gatherings, 65% limiting contact with at-risk individuals, 33% self-isolating due to symptoms, and 26% self-quarantining after possible exposure. Participants with known COVID-19 infection pre-enrolment were more likely to self-quarantine after possible exposure although asymptomatic (65.0% vs 23.4%, p < 0.001; Chi-square test). Participants with multiple comorbidities more likely endorsed physical distancing (85.7% vs 75.5%, p = 0.044; Chi-square test), although this was not significant in logistic regression analysis adjusted for age, sex, race, number of household members, number of bedrooms/bathrooms in the household per person, influenza immunization, and working in close physical proximity to others. Overall, participants reported frequent practice of preventative behaviours.

from 10 to 21 percent . Changes in child-bearing rates within subgroups and recent immigration trends have further contributed toward dramatic populations shifts . At the same time, leading educators and policymakers note the challenge of working with diverse populations and the importance of closing the achievement gaps often associated with them . For several decades, schools of education and national accreditation agencies have recognized the need to train candidates in the "knowledge, skills, and professional dispositions necessary to help all students learn" . These groups also agree that all educators, even those who are themselves from diverse backgrounds, must acquire new perspectives to effectively instruct students across broad socioeconomic and ethnic/racial groups . --- TEACHER EDUCATION CONTEXT Many candidates, particularly those from a relatively homogeneous White, middle-class background, may have limited exposure to the diverse populations they will be called upon to teach. At our institution, for example, the student body is 92% White, while less than 1% is Native American, even though the state population is approximately 10% Native American . This demographic pattern of predominately Caucasian teachers generally holds true across the country. According to the National Center for Education Statistics Schools and Staffing Survey 2010 data, 83% of elementary and secondary teachers are White; 7% are Black and 7% are Hispanic . One concern expressed in the literature is that White teachers with limited experiences with diverse student populations might have lower expectations for low-income and minority learners . In We Can't Teach What We Don't Know: White Teachers, Multiracial Schools, Howard explored how lack of exposure to other cultures may result in fear. Our reaction to fear, he theorized, determines whether or not we grow in multicultural understanding or remain socially isolated. Howard emphasized that teacher preparation programs must look for ways to bring candidates out of isolation by developing in them the competencies necessary to "become partners in the dance of diversity" . AUTHOR NOTE: Mary R. Moeller,Ed.D.,assistant professor,Teaching,Learning,and Leadership Department,Box 0507,South Dakota State University,Brookings,M.A.,M.F.A.,instructor,English Department,South Dakota State University. Moeller, Bielfeldt / SHAPING PERCEPTIONS 83 --- TEACHER PERSPECTIVES THAT LIMIT CLASSROOM EFFECTIVENESS One of these critical competencies is a professional expectation that all students can succeed. Villegas and Lucas have emphasized the importance of believing that all students can learn and deserve equal access to educational opportunities. To ensure that all students have such equal access, reform is needed. Ullucci argued, however, that because educational beliefs and teacher perspectives "form the bedrock on which we build educational policies and practice" , school-wide reform is significantly hampered when educators hold negative perceptions. If candidates enter the profession with foregone conclusions about student abilities, they expect less, see less, and get less. From this mindset emerges a cultural deficit model, characterized by descriptions of people and their cultural values as "pathological, [and] deficient in the cognitive, emotional, linguistic, and spiritual resources" . The cultural deficit perspective attaches labels and identifies weaknesses in students' backgrounds, suggesting that "children of color [are] victims of pathological lifestyles that [hinder] their ability to benefit from schooling" . Furthermore, when educational systems place the blame for low achievement in their students' homes and cultures, system-wide practices and policies contributing to the problem are often overlooked . Shaping teacher beliefs at the pre-service level remains a significant challenge in combating such oppressive perspectives and systems . At the same time, working toward this reform is a significant goal for teacher preparation programs to embrace, particularly because once teachers are placed within a school, their perspectives may become influenced by the system, making it more difficult for them to change their perceptions. --- CRITICAL RACE THEORY IN TEACHER EDUCATION CONTEXT Critical approaches in research look beyond examining and understanding to include a larger goal of reforming and improving . Bell, Crenshaw and Delgado popularized the Critical Race Theory framework in the 1970s to identify systemic racism . Subsequently, it has been utilized as a critique in many disciplines, including teacher education . As a teacher educator who promotes multicultural education, Vavrus has suggested that adding knowledge of CRT to the teacher education curriculum could foster increased cross-cultural competencies. Yosso ) also affirmed CRT as a basis for examining the ways that race impacts schools. Two central tenets of CRT are particularly relevant for teacher education: 1) CRT challenges "the traditional claims of the educational system and its institutions to objectivity [and] meritocracy" ;1 and 2) CRT places a value on the experiences and applied knowledge of minority cultures , examining the lives of real people to understand how actual events have shaped their understandings and status. CRT asks educators to consider what important experiences minority students bring to school and how those experiences might be viewed as resources increasing the students' likelihood of success. Both CRT and applied learning place experiences at the center of the learning process. Although developmental theorists such as Piaget have focused on the formal learning process as occurring in stages prior to adulthood , CRT has emphasized that lived experiences throughout one's entire life can bring insight and knowledge to learning . Schwartzman and Henry likewise note "the true test of knowledge lies in its connection to lived experience" . Yosso has applied CRT's approach of valuing student experiences to Chicano/a students and identified specific categories of what she terms "community cultural wealth" . These CCW categories identify an "array of cultural knowledge, skills, abilities and contacts possessed by socially marginalized groups that often go unrecognized and unacknowledged" . CCW, thus, offers concrete alternatives to the cultural deficit perspective and serves as a means to challenge the social injustice that Yosso believes is endemic in schools. CCW guides teachers to acknowledge the strength of culturally-related attributes, such as bilingual homes and large extended families, instead of seeing those qualities as barriers to success ). --- COMMUNITY CULTURAL WEALTH MODEL The CCW model defines six forms of cultural "capital" , which often overlap and intertwine: 1. Aspirational Capital: the resilient nature of people who hold on to their "hopes and dreams for the future, even in the face of real and perceived barriers" . 2. Linguistic Capital: the "skills attained through communication experiences in more than one language and/or style" , including communication through musical and visual arts. 3. Familial Capital: the ways that "familia …carry a sense of community history, memory" . 4. Social Capital: the "networks of people and community resources…both instrumental and emotional support to navigate through society's institutions" , extending the concept of familial capital into a broader and more extensive system of relationships to provide information and reinforce confidence. 5. Navigational Capital: "skills maneuvering through social institutions" or the ability to work and even thrive in hostile and unresponsive environments. 6. Resistant Capital: "those knowledges and skills fostered through oppositional behavior that challenges inequality" or asserting oneself in the face of repression. --- INTEGRATION OF COMMUNITY CULTURAL WEALTH INTO TEACHER EDUCATION CURRICULUM The basic principle of identifying strengths in other cultures as a foundation for building positive expectations is well-grounded in crosscultural theory. "Both learning and development are deeply embedded in cultural contexts.... Teachers must understand and appreciate the variety of ways children's experiences can differ, and be able to see and build upon cultural strengths if they are to help all students succeed" . However, little research has been conducted that investigates the integration of CCW in teacher candidates' experiences working with Native American populations. --- METHOD This study describes the initial steps taken to integrate CCW theory into a required teacher education diversity course as it partnered in a service-learning project with a federally operated Native American boarding high school, the Flandreau Indian School. This partnership operates within the Flandreau Indian Success Academy , a crosscultural program that encourages the university at large to adopt the CCW perspective of "respect for the families, communities and tribes from which our students come" . 2 Within the FISA, teacher education instructors created a workshop specifically for the College of Education and Human Sciences. Teacher education faculty recognized that candidates are not immune from believing the stereotypes prevalent in today's society about Native Americans as either desperately poor or newly rich from casino profits . To achieve the two project goals of breaking these stereotypes and of replacing them with an asset-based perspective, instructors added lessons on CCW and then assessed the candidates' application of the content during a service-learning experience-hosting an FISA workshop. During the FISA workshop series, freshmen from a Native American high school came to SDSU seven times to experience higher education opportunities. Each college in the university prepared its own three-hour workshop, with students rotating through in small groups. The workshop experience described in this study was hosted by the College of Education and Human Sciences with candidates leading the following activities: a ten-minute icebreaker in small groups; an introduction to Multiple Intelligences Theory ; an online assessment of multiple intelligences , followed by a one-to-one discussion of the implications for candidates and students; and a creative project where students decorated quilt squares to reflect their personalities. Each FISA workshop concluded with a dinner, which gave additional time for interaction. Two research questions guided this study: 1. Do candidates apply their knowledge of CCW in reflecting on their face-to-face interactions as hosts for the FISA students in the FISA workshop? 2. Which types of community cultural wealth capital do candidates identify most frequently as they reflect on their FISA experiences with Native American students? Prior to hosting the FISA workshop, candidates in the education course on Human Relations received the following uniform curricular materials and experiences: 1. A reading and discussion of "Turning the Notion of 'Community' on Its Head: SDSU-Flandreau Indian School Success Academy" as background for serving as hosts in the FISA workshop. This article also briefly explained the CCW concept and challenged the deficit model of using labels to depict diverse students. 2. A presentation on FISA by the SDSU coordinator. A class activity following the lecture served as a formative assessment, indicating to the instructor that the candidates could identify and explain the six categories of capital. For a summative course assessment, instructors used the following three reflection prompts related to the course content goals of applying their knowledge to the service-learning setting, as suggested by Ash and Clayton . 1. Describe what the FISA experience was like for you. Think of the roles you played in all components of the workshop. Which role felt the most successful from your perspective? Why? 2. What did you discover about yourself as an "intentionally inviting" teacher ? 3. What did you discover about working with the FISA students? Thirty-eight candidates constructed their responses during the last week of class to reflect their FISA experiences and, as such, the reflections were identified as data "indicative of the phenomena of interest" . Candidates in this course signed informed consent statements that indicated their understanding that their written submissions could be used for research and that assured them of confidentiality related to their participation. The responses were collected by a graduate student to ensure anonymity and to encourage the construction of honest responses. Content analysis was selected as the most appropriate method to use because the responses provided insight into candidates' perceptions of Native American students, thus enabling researchers to draw inferences . --- RESULTS AND ANALYSIS Initially, six categories of CCW were used as the basis for coding; however, the two researchers decided to collapse the Social Capital and Familial Capital categories because of the difficulty of defining these as mutually exclusive within this population. Research on educational questions are often complex and require interpretation and discovery as methods of inquiry . Each constructed response was coded independently by the researchers by identifying themes that matched the CCW capital categories, as defined earlier and as revised above. The researchers initially coded 27 out of 38 responses in agreement, with agreement defined as identifying the same CCW categories in each response. Responses with codings outside the range of agreement were re-read, discussed by the two researchers, and, based on their discussion, a consensus was reached for all responses. The coded responses were tabulated by category, and the category totals were converted to percentages of the total responses. The first research question asked if candidates applied knowledge of CCW in reflecting on their face-to-face interactions with the students. Twenty-seven candidates' responses exemplified an ability to apply knowledge of CCW during the service-learning activity; eleven candidates' responses did not show this ability. Only one candidate specifically mentioned the CCW theory in the response; however, the constructed response prompts intentionally elicited a broad range of ideas to evaluate the transfer of classroom knowledge to experience. Overall, the results indicate that a more intensive focus is needed on CCW theory if it is to be applied successfully in the field. The second research question asked which types of capital candidates tended to identify in their reflections. Table 1 illustrates the percent of candidates who identified a certain CCW category in their constructed responses. --- CATEGORIES OF CONTENT Candidates most frequently identified Social/Familial Capital and Aspirational Capital in their responses as they reflected on their FISA experiences. Conversations about family and friends were apparently frequent topics during the workshop, which would account for the high percentage of codes in the Social/Familial category. Evidence of close friendships among the FISA students was noted in this response: "The two girls we had were good friends so that also helped with the awkwardness." In considering combining the categories of Social Capital and Familial Capital, the instructors noted that Native Americans often have broad definitions of who is considered family, and extended family relationships in vertical and horizontal directions can blur the lines between family circles and social circles . The English instructor who had also previously worked with the FISA students noted this in the language they used to describe family members. For example, one student told her, "My mother is my grandmother," and in another instance, a student referred to his friend as "Brother" in an essay. When the instructor suggested changing the term so as to not confuse his readers, both students protested. A Lakota saying that illustrates this global perspective of claiming relationship with all people and, in fact, all living things is Mitakuye Oyasin or "All My Relatives." The decision to collapse the social and familial capital categories aligned with what the instructors perceived as Native American cultural values and perspectives. Responses were coded as Aspirational Capital in reference to conversations about future plans, such as: "She was very interested in a science field…and hoped to come back again." In the context of the FISA workshop, it is likely that school and careers were logical topics of conversation between FISA students and candidates, which could explain the higher frequencies of this category. Navigational Capital was identified when candidates commented that FISA students were able to overcome their initial shyness and became engaged in the workshop activities, for example, "by the time we started working on the crafts,…they felt free and were able to speak their minds." Linguistic Capital includes abilities in music and visual arts. Several candidates were surprised by displays of FISA artistry during the creative activity, as exemplified by this response: "What she [FISA student] drew in thirty minutes blew me away." However, few responses indicated an awareness of this resource. Although the instructors did not identify any response as having made thematic connections to Resistant Capital, the instructors noted that responses included references to non-compliant behavior from the FISA students . However, the candidates did not appear to perceive the negative behavior through the lens of Resistant Capital. Overall, the results indicate that a more intensive focus is needed on CCW theory if it is to be applied successfully in the field. In addition, other themes that emerged through the researchers' discussions indicated additional pre-workshop interventions might be beneficial. --- EMERGENT THEMES IN THE CONSTRUCTED RESPONSES During the researchers' discussions about the content of the constructed responses, several other themes of interest to teacher educators emerged. The following themes were perceived to be most evident and significant for future study. Candidates most frequently identified Social/Familial Capital and Aspirational Capital in their responses as they reflected on their FISA experiences. Conversations about family and friends were apparently frequent topics of conversation during the workshop, which would account for the high percentage of codes in the Social/Familial category. Evidence of close friendships among the FISA students was noted in this response: "The two girls we had were good friends so that also helped with the awkwardness." In considering combining the categories of Social Capital and Familial Capital, the instructors noted that Native Americans often have broad definitions of who is considered family, and extended family relationships in vertical and horizontal directions can blur the lines between family circles and social circles . The English instructor who had also previously worked with the FISA students noted this in the language they used to describe --- EMOTIONAL RESPONSES More than half of the candidates reported experiencing various levels of anxiety about the FISA workshop as they anticipated their role as hosts and as they engaged with FISA students. Their comments ranged from feeling "out of my element a little bit" to "nervous to the point of jitters." Howard points out the significance of these reactions: "Whether we deepen our awareness and continue to grow through such experience or merely shrink back into the safety of isolation, is determined by our reaction to the inevitable fear of stepping outside the boundary of ignorance" . Guiding candidates through this emotional transition will most likely require more intensive intervention. --- PERCEPTIONS OF SUCCESS Several candidates reflected upon their perceived success, most notably equating success with interpersonal connections they made with the FISA students. For example, "we feel as though we succeeded when we see a smile or even when we see someone opening up." Another wrote, "I felt the classroom went very well when the girls were making their postcard things. By that time everyone had opened up to one another and there was a lot of visiting happening as opposed to awkward silence." A third candidate reported that the "most successful" part was when he was able to "invest and get to know a student." The candidates also reported success when the FISA students were fully engaged with the workshop activities and reported a corresponding lack of success when the FISA students "didn't seem to want to be involved." One candidate, for example, reported a lack of success when she "didn't feel [her] student was doing what she should have been doing." Pratt argued, however, that such self-reports of success within what she calls "a contact zone" should be questioned. She defined contact zone as "social spaces where cultures meet, clash, and grapple with each other, often in contexts of highly asymmetrical relations of power" -which arguably was the case with the FISA, where mostly White candidates met with Native American high school students. --- PERCEPTIONS OF LACK OF SUCCESS Several responders noted other instances in which the FISA students did not respond as expected or desired. For example, they reported instances of FISA students "joking around," "going on Facebook during computer time," and "having a bit of an attitude." Pratt , however, noted that when social situations are "described in terms of orderliness, games, moves, or scripts, usually only legitimate moves are named as part of the system, where legitimacy is defined from the point of view of the party in authority" . In other words, when the FISA students did not do what was expected, when they did not follow the game or script, the candidates did not count it towards success. In discussing the responses, however, the instructors wondered if some of the "illegitimate" moves on the part of FISA students might, in fact, be unrecognized Resistant Capital. For example, one candidate reported that a FISA student called a drawing activity "stupid," then proceeded to write the word DEATH on his paper. Another FISA student drew an elaborate dragon which was swearing. Several candidates reported other behavior on the part of FISA students, behavior which the candidates considered rude and troubling. Might these behaviors, in fact, have been evidence of Resistant Capital? Pratt asked, "What is the place of unsolicited oppositional discourse...? Are teachers supposed to feel that their teaching has been most successful when they have eliminated such things and unified the social world, probably in their own image?" Another example of possible misinterpretation is the number of candidates who expressed frustration at perceived lack of attention. For example, several responses noted that FISA students put their heads on their desks. The researchers wondered, however, if such action, which again does not fall within the imagined ideal classroom behavior, might indicate close and attentive listening-the opposite of how candidates perceived it. Might not cultures with strong oral traditions also foster strong listening skills, and might that listening be perceived differently by those from a culturally distinct background? --- CHANGING PERCEPTIONS AND ATTITUDES Finally, several responses indicated disconfirmed expectations about the FISA students and the experience in general, demonstrating a changed perception in the candidate. One respondent wrote, "I misjudged them all. My thoughts were that these students are mean, students who do drugs, and that they never listen. That was me being ignorance [sic] because what I came to find out is that they are just students who need a little help or push to get along." Another particularly self-aware candidate wrote, "I learned...that I am not as openly inviting as I wish I could be." --- LIMITATIONS The use of content analysis as a research methodology limits the findings from this study in several ways. The researchers made inferences based on their interpretations of candidate responses to determine perceptions and attitudes towards FISA students; however, "inferences never yield absolute certainties" . The researchers used an established theory, Yosso's community cultural wealth theory, as the basis for coding categories, and "established theories relating data to their context are the most unequivocal sources of certainty for content analysis" . However, CCW was developed in the context of Hispanic experiences ; although there may be similarities between the Hispanic and Native American cultures, the validity of CCW has not yet been tested in a Native American content. Although the constructed responses that served as the data for this study were collected in an anonymous way, one of the researchers was also a course instructor. Her knowledge and personal observations of the candidates may have introduced some evaluator bias into the findings. The second researcher had no knowledge of the candidates. Although candidates were assured that their responses would not be graded for content, some responses may have been written with the instructor as an audience in mind. This may have influenced the perspectives the candidates presented. The scope of the three-hour FISA workshop limited the ability of candidates to more completely know the FISA students, and thus limited the candidates' amount of information on which they based their responses. Finally, the assessment of the integration of CCW into the teacher education program relied heavily on candidate self-reporting, which "also invites systematic bias" . Because candidates likely know what answers the instructors want, and because the candidates' positive reports will also affirm their personal growth as future teachers, exaggerated responses were possible. --- IMPLICATIONS AND SUGGESTIONS FOR FUTURE RESEARCH Yosso concludes her book Critical Race Counterstories along the Chicano/Chicana Educational Pipeline with this haunting question: "Can education-rooted in a sense of community responsibility and with a goal of racial and social justice-transform society?" This study explored the use of an intervention to shape candidates' perceptions and attitudes by including Critical Race Theory and community cultural wealth theory in a required diversity course. Yosso's categories appeared appropriate for use with Native American students with the possible exception of two forms of capital. The researchers found that distinguishing between Social Capital and Familial Capital in candidates' responses was difficult because some 93 Native American cultures, such as Lakota, embrace a global perspective of relationship. Formative assessments indicated that candidates were able to identify different cultural capitals. However, in the summative assessment of this knowledge as applied in the FISA, 59% of the candidates included elements of CCW capital in their reflective responses describing the students while 41% of the candidates did not. The results indicate that a more intensive classroom and field focus on CCW theory is required. Some candidates' responses also suggested that more pre-workshop activities to acquaint the two populations with each other might be beneficial. Several candidates noted that both they and the FISA students felt "uneasy" or "awkward" and needed time to "warm-up" to each other. In addition to Yosso's categories of CCW, the instructors are interested in the way she distinguishes between "majoritarian" and "counter-stories." Both recount the experiences and perspectives of individuals. Majoritarian stories are told by those with racial and social privilege, but counterstories are told by socially marginalized people. Pratt also defined "auto-ethnographic texts" as those which "people undertake to describe themselves in ways that engage with representations others have made of them" . Perhaps one pre-workshop activity might be for all members of the two populations to create and share narratives about their own lives, so that the "warm-up" period of the workshop might be more quickly navigated. Digital Storytelling 3 might be one form of narrative that the students could use to become more familiar with each other before meeting. Wiconi Waste: Education, an existing social networking site, could provide the platform for sharing the stories. This private social networking site was developed as a communication link between the two service-learning partners, FISA and SDSU teacher education students. Another useful addition to the applied learning experience might be to develop Pratt's suggestion for "ground rules for communication across lines of difference and hierarchy that go beyond politeness but maintain mutual respect" as a way to enhance cross-cultural communication skills. --- CONCLUSION Teacher educators know that candidates need significant experiences to learn about and to interact with diverse students, especially in light of current demographic trends with the school-age population. However, experiences have the potential to move people in different directions; this means that each classroom experience must be evaluated on "the ground of what it moves toward and into" . Instructors should look for evidence that their course curriculum provides valuable learning opportunities that enhance and broaden candidates' perspectives and that such learning connects classroom theory with field experiences . If candidates can be taught to view their future students through the lens of an asset-based perspective such as CCW, candidates might reject the stereotypical views about diverse students. This study showed that over half of the candidates were able to access their knowledge of CCW capital as they reflected on their interactions with Native American students, but some forms of capital were apparently more identifiable than others within the context of this study. Further investigation is needed to determine what potential exists for shaping future teachers' attitudes and perceptions of Native American students through the integration of CCW theory into the teacher education curriculum. Utilizing a curriculum that enables candidates to identify the strengths of diverse cultures might also enable future teachers to create more culturally relevant lessons. Identifying and valuing cultural capital might allow candidates to gain insight into their own students, which also allows pre-service teachers to make more meaningful connections. By learning "important community strengths" or identifying "a community's funds of knowledge" , candidates develop an especially vital cultural competency: the ability to view their future students in a positive light, as described in this response: "I saw that many of them wanted to achieve more than just the simplicity of life; they wanted to become something more. The passion for education." Indeed, for any service in which the recipient is lower in the power hierarchy than the provider, a clearer understanding of the strengths of the recipient's community network will serve to balance the relationship and enhance the significance of the learning experience.

Teacher candidates need to be prepared to work effectively with rising numbers of diverse student populations, and yet classroom interventions do not always impact perceptions and attitudes in the field. This study explored the initial steps of integrating Critical Race Theory and community cultural wealth (CCW) theory (Yosso, 2005(Yosso, , 2006) ) into the teacher education curriculum. The study asked if the candidates applied their knowledge of CCW in reflecting on their face-to-face interactions as hosts for Native American students in a diversity workshop. It further asked which types of (CCW) capital the candidates identified most frequently as they reflected on their experiences with Native American students. Results indicated that candidates can identify CCW in the field, with some types of capital more frequently identified than others. Because the potential exists for knowledge to shape perceptions (Kolb, 1984), the study concludes that CCW could be a valuable addition in teacher education curriculum. A more intensive focus on CCW and the addition of pre-contact activities, such as the sharing of counterstories (Yosso, 2006), may also promote knowledge translating into perception and attitudes. The 2010 U.S. Census affirmed projected demographic shifts: American classrooms will increasingly include children and youth from diverse populations, resulting in a decrease in the proportion of non-Hispanic White students (U.S. Census Bureau, 2010). Specifically, from 1986 to 2008 the percentages of White students decreased from 70 to 55 percent, while the overall percentage of Hispanic students rose

Introduction As the problems that society is facing today are too complex to be tackled by only one institution, the literature states that organizations from civil society and the public and private sectors must collaborate to solve social, environmental and economic challenges [1][2][3][4]. To address these issues, more than 10,000 local governments around the world have implemented sustainable community plans in their cities since 1992, any of which are collaborative in nature [5]. When organizations from different sectors bring their diverse skills together, they can create new capabilities that help with solving unsustainable challenges [1,6,7]. This form of collaboration, when formed into an entity, is called a cross-sector social partnership [8]. The number of CSSPs has been increasing at both global and local levels due to the benefits that they bring, not only to sustainability in general but also to their partners, including resources and skills [1,7]. Research showed that structural features within the partnership, such as the means of communication, partner engagement strategies, decisionmaking structures, monitoring and reporting, help partner organizations achieve their own goals [9] since they have the capacity to transform strategic goals into positive outcomes [9]. The structural arrangements of partnerships vary [10], thus impacting outcomes [11]. In this study, the outcomes of partner organizations are understood through an extended version of the resource-based view . The RBV includes human, physical, organizational and financial capitals [12]. Human capital refers to the knowledge developed by the people working in an organization; physical capital is related to the technology and location of a firm; organizational capital refers to the procedures and culture of a firm, such as the means of reporting; and financial capital is the earning, debts and equity of an organization [13]. The extended RBV includes the natural-resource-based view approach proposed by Hart [14] and socio-ecosystem resources [1]; this is called community capital in this study. Despite past contributions, there is still a gap in the research of the relationship between the structural features of a large CSSP and the outcomes that partner organizations can obtain by participating in CSSPs. In addition, little attention has been given to the structuring of partnerships [10]. Large CSSPs have been selected for this study, not only because they are understudied but also because the literature suggests that they are more powerful than small partnerships due to their diversity and size, which helps partnerships to address the variety of challenges identified as key in the cities' sustainability plans [9]. To fill in this gap, this study explored the relationship between the structural features of three large CSSPs that all aim to contribute to the achievement of sustainability goals for their cities: Barcelona + Sustainable in Barcelona, Spain; Gwangju Council for Sustainable Development in Gwangju, South Korea; and Sustainable Montreal in Montreal, Canada, and the outcomes their partner organizations have achieved during the implementation of community sustainability plans. This research aimed to analyze the partnerships' structures and determine which structural features are present for each CSSP, analyze the value that partner organizations from different sectors and partnerships give to their achieved outcomes, and analyze the relationship between the structural features of the CSSPs and the partner outcomes. The relevance of this topic is that the design of partnerships affects their ability to achieve their desired sustainability outcomes [11]; therefore, knowing more about structuring partnerships will enable better design of governance structures, thus ensuring desired partner outcomes can be achieved. --- Cross-Sector Social Partnerships Cross-sector social partnerships are typically a voluntary form of collaboration, although some are mandatory [15], where organizations from the civil society, the public sector and/or private sector partner with the purpose of solving social problems of mutual concern [8]. Many of the complex issues that different societies are facing, such as the creation of sustainable communities, need strong CSSPs to solve them [1]. Small CSSPs have two or three partners from two or three sectors, and large CSSPs or multi-stakeholder partnerships have multiple partners from the three sectors [9]. Large CSSPs tend to be more inclusive since the participation of many partners is required, while the partners of small CSSPs are selected for a specific fit [9]. --- Partnership Structures The interest in partnership design has grown due to a variety of challenges related to resilience and environmental sensitivity, among others [10,16]. The design stage is important since the foundation and key elements for the success of a partnership, such as the relationship and roles between partners, how the partnership is structured in terms of formality, continuity, governance and coordination, as well as the allocation of resources, are sorted out in the design process [17]. As organizations are part of the external environment with which they interact and engage for resources and in which they have interests, they must structure themselves according to the contexts they face [18,19], and this is not different for partnerships [20]. Within the CSSP literature, structures are "a key driver of the way agendas are shaped and implemented"; they affect the things organizations do by determining key factors around influencing power and resources [21], p. 1166. Research showed that an effective method of encouraging successful cross-sector collaboration is through the implementation of structures [9] that allow for the achievement of collaborative goals [22]. Structures have the capacity to transform strategic goals into outcomes due to the interactions between different organizations, through decision making, through being involved in the process and actions, and by exchanging resources that are necessary in order to achieve desired outcomes [9]. As argued by contingency theorists, they must be designed according to the environments they face, i.e., formally when facing certainty and informally whenever dealing with complex issues, such as those presented by sustainability challenges [18]. Due to the lack of attention being given in the literature to structures for implementation in large CSSPs [9,10], this research considered the structural features adopted by different authors and then developed a framework to analyze the structural features of the partnerships. --- Structural Features of Large Cross-Sector Social Partnerships This study considers seven categories to organize the CSSPs' structural features: communication systems, monitoring and reporting systems, partner engagement, coordination entity, renewal systems, decision-making systems and the composition of the partnership. Something that is not considered in this paper but is also an important structural feature of partnerships is resource allocation [23]. Several authors considered communication systems as an important component of cross-sector partnerships. In particular, Koschmann et al. [24] stated that communication systems are a key factor within organizations and collaborations. For Clarke [22], as well as for Kuenkel and Aitken [25], new communication systems are established for the implementation phase of a partnership. A partnership for the improvement of health finance policies in Ghana and Kenya demonstrates the importance of structured ongoing communication systems to develop a strong relationship and mutual understanding between the public and private sectors [26]. Some scholars also indicated that communication with multiple stakeholders is critical for strengthening relationships at multiple scales [27]. Some of the factors that allow for successful partnerships are monitoring and reporting systems [26]. It was shown that when there is a lack of these structural features within a partnership, it lowers the ability to achieve long-term goals [28]. Rein and Stott [28] studied six cross-sector partnerships in Southern Africa that had a lack of monitoring and evaluation processes, which made it difficult to evaluate the benefit of the partnership for the partners. Monitoring and reporting can focus on the sustainability impact [23,29] and/or on the process and actions [30,31]. Partners' engagement is helpful within collaboration systems to engage key partners and attract new organizations [32,33]. Adding new partners is also an important component of partners' engagement [34]. In terms of resources, new partners enable the achievement of the partnership's common goals, allowing for the continuity of the collaboration systems [17]. Coordination helps to organize the activities where partners participate in order to achieve the partnership's goals. It can also organize the resources provided by each partner [35]. According to Kamiya [17], coordination can be done through hosted secretariats, separate secretariats or without secretariats. When a partnership has a hosted secretariat, one lead partner oversees the secretariat, which reflects a medium level of institutionalization. A separate secretariat means that the partnership creates its own coordination means [17]. Therefore, the secretariat is separated from the partner organizations, which have their own staff and space, although the cost of the partnership might be higher than having a hosted secretariat [17]. This modality can be considered a high level of institutionalization [17]. A low level of institutionalization is reflected through partnerships that do not have a secretariat that coordinates the partnerships' activities. The way that this modality functions is that one or more partners play the role of a coordinator when it is needed [17]. It is quick and it does not need many resources, which might work better for a small, start-up partnership with a restricted budget [17]. Renewal systems are relevant for cross-sector partnerships due to their iterative and nonlinear path toward achieving goals [22]. They create opportunities for collaborative advantage [35], learning and building relationships [36] and allowing partners to adapt to new challenges [22]. Renewal systems also help to assess how resources are being managed; in order to reach transformational goals over time, adjustments are likely needed to the partnership goals and design [37,38]. Decision making is a collaborative arrangement set in place to govern strategy formulation and implementation [22]. The involvement of partners in decision making is often related to an improved capacity for the partnership, as it is able to adapt to changing circumstances [39]. In terms of the allocation of authority, the question lies in who makes the decisions and at which organizational level. Mintzberg [40] states that when power for decision making resides in one entity, then the structure is centralized. Contrarily, when power is shared among entities, then the structure is decentralized [40]. Kamiya [17] states that it is important in large partnerships to define which partners are going to be part of the decision-making process because not all the partners are involved in that way. This is different from the case of small partnerships, where most of the partners participate in the decision making of the partnership [17]. For complex arrangements, such as large CSSPs, decentralized decision making with a proper coordination and monitoring mechanism is an appropriate design [22]. The composition of the partnership is considered in this study as part of the structural features. That is, the longevity of the partnership, size and sector make-up of the partnership. The length of time of the partnerships is considered as the time that the partnerships have been operating, which is likely to have an effect, either positively or negatively, on their outcomes [1]. Partners can develop relationships and processes that are needed for the implementation phase; however, longstanding partnerships might face partner fatigue as one of their outcomes [9]. In terms of size, several authors stated that the structures that partnerships implement might be different depending on the size [17,22,41]. Lastly, studying the predominance of the sector in cross-sector partnerships is relevant, as the literature suggests that organizational partners have different levels of capacity and capabilities based on their sector, although not necessarily different types of outcomes [1,9]. Therefore, the structures within the CSSPs examined in this research may vary regarding their composition. --- Partners Outcomes: Extended Resource-Based View for CSSPs The framework that was used to understand partners' outcomes in this research was an extended RBV approach. The RBV considers that resources that firms consider valuable are scarce [12]; therefore, partnerships become a strategic approach that allows organizations to have access to other organizations' resources [42]. The RBV is based on a hierarchical classification of the partners' resources, which means that partners value some resources more than others [14]. The value assigned by the partners to some resources over others depends on the returns that these resources bring to organizations [9]. One of the values of joining a partnership is the idea that partners can accomplish outcomes that they could not achieve alone [1]. Although some authors claim that partnerships do not prioritize strategies for the needs of the partners [43], recent research showed that partners positively value their results when joining a CSSP [9]. Several studies compiled long lists of partner outcomes from CSSPs [1,44] which were also used for this study. There are some specific outcomes by sector, both positive and negative, that partner organizations could gain when they join a partnership [1]. However, previous empirical studies on large cross-sector social partnerships did not show differences between the resources achieved by the partners when considering the sector they came from, e.g., [9]. This study considered the question of sector-specific partner outcomes in each of the three partnerships. The study only considered positive outcomes, as that is what the respondents to the survey used in this research reported. --- Partnership Structure to Partner Outcome Relationship Literature related to cross-sector social partnerships argues that this type of arrangement creates the necessary conditions for partners to have access to resources that are valuable for them [45] and contribute to sustainability challenges [46]. At the same time, partners contribute to the sustainability plan of the community by implementing the sustainability strategies that were outlined in the plan; tracking the progress of the goals; and identifying opportunities for improvement, which allows for progress [1]. The implementation of a sustainability plan relies not only on the structural features adopted but also on a deep understanding of the benefits that partners can have by joining the partnership, which helps keep them involved. Empirical research showed that partners can gain physical/financial, human and organizational capital when they join a partnership [15]. Despite the importance of the role of the partners in CSSPs, there has not been much research undertaken that relates to the relationship between the structural features of a large partnership and partners' outcomes. The aim of this research was to contribute to that field by researching three large CSSPs for the sustainability of Barcelona, Gwangju and Montreal. --- Material and Methods The selection criteria for this multi-case study are listed below [47]. These criteria enabled the study of large CSSPs that have existed for at least 20 years and are intended to continue to exist into the future, impacting similar populations so that the size of the city did not influence the comparison. --- • The CSSPs had at least one hundred partner organizations confirmed, who were from civil society, public and private sectors; • The CSSPs had a community sustainability plan with a long time horizon and a history of implementing sustainable community plans for more than 10 years; --- • The size of the community impacted by the partnership was from 1 to 2 million people; • Partners were highly engaged in the partnership [8], contributing to at least some of the sustainability goals of the sustainability plan; --- • The partnerships were from three different countries and continental contexts. --- Selected Cases The community sustainability plans of each partnership are introduced here. The partnership structures are presented in the results. --- Barcelona + Sustainable The sustainable agenda in Barcelona has been a priority since 1995 when the City of Barcelona committed to the creation of Local Agenda 21 [48]. Their latest public commitment and the plan considered in this research was their 2012-2022 sustainability plan with goals and objectives that focused on public spaces and mobility; environmental quality and health; efficiency, productivity and zero emissions; the rational use of resources; good governance and social responsibility; well-being; progress and development; education and citizen action; and resilience and planetary responsibility [49]. --- Gwangju Council for Sustainable Development Local initiatives for sustainable development in South Korea were introduced in 1995, and Gwangju has been one of the cities working for sustainability since then [50]. The main goals of the Gwangju Council for Sustainable Development are encouraging local participation, as well as focusing not only on environmental issues but also integrating the scope of the initiative on economic, social and cultural matters [51]. The main topics of the 2017-2021 plan were clean water, air and energy; city forests; a city safe from chemicals; recycling of materials; green and social economy; urban farming; a welfare-sharing, diverse, healthy and beautiful community; a people-oriented traffic system; residential environments; and education for sustainability [52]. --- Sustainable Montreal At the Montreal Summit held in June 2002, the City of Montreal committed to sustainable development. Montreal's third Community Sustainable Development Plan 2016-2020 focused on four priorities: GHG emissions and dependence on fossil fuels; adding vegetation, increasing biodiversity and ensuring the continuity of resources; ensuring access to sustainable, human-scale and healthy neighborhoods; and making the transition toward a green, circular and responsible economy [53]. The study's methods and results are presented in three parts. The first part presents the structural features of each partnership. The second part presents the partners' outcomes, and the third part considers the relationship between the structures and outcomes. --- Qualitative Study --- Data Collection The information about the partnerships' structures was collected during the ICLEI World Congress held in Montreal in June 2018. The directors/coordinators of the partnerships were asked about the structure of their partnerships through semi-structured interviews that were recorded by video. The interviews were mainly focused on the structural design of the partnerships. Further questions were answered by the directors/coordinators either by email and/or phone call to complete the structural features framework of this study. --- Data Analysis The content was coded through qualitative content analysis [47] based on the deductive framework from the literature review, i.e., the partnership structural features. Next an inductive round of coding was completed on the interview transcripts to see what additional codes or sub-codes were needed to further categorize the data in a comparable way . --- Quantitative Study Data about the partners' outcomes were gathered through a cross-sectional online survey conducted between June 2015 and June 2017 that was offered in three languages-French, Spanish and Korean. Partner organizations were asked to value the outcomes according to a 5-point Likert scale from 1-very valuable to 5-not valuable. Outcomes were organized into five groups: organizational, human, physical, financial and community capitals following the extended version of the RBV. --- Data Collection Data collection happened in two stages. First, an online invitation was sent out by the secretariats of the partnerships to all their active partner organizations, asking them to respond to the online survey. The active partners are organizations that are currently participating and are committed to contributing to the sustainability goals of the CSSP. If the number of responses needed was not reached to make the results generalizable, a second recruitment effort was conducted by sending an email to active partners inviting them to complete the same survey through a personal meeting. Table 2 shows the number of partners that completed the survey in each partnership. --- Data Analysis The response bias was calculated using wave analysis and no response biases were found among the partnerships, i.e., variances could be assumed to be equal with respect to the assessed variables . The data analysis included the creation of indices based on RBV capitals, including community capital. The survey questions used to create the indices were as follows: "As a result of remaining a partner of the partnership, your organization has achieved . . .". Partners had the option to rate the achieved outcomes on a 1 to 5 scale, where 1 was "Very Valuable" and 5 was "No Value". Table 3 shows each of the capitals with their corresponding items. The indices were created by combining the items that measured each capital. To test the internal consistency of each index, Cronbach's alpha test was used, and it was found that all coefficients were greater than 0.70, confirming the internal consistency [54] . Once the indexes were created, given that the data were not normally distributed, Kruskal-Wallis tests were used to compare the means of the indexes by CSSP, and then by the sectors of each CSSP. This study employed version 25 of SPSS Statistics software to conduct the statistical analysis. --- Explanation Building Study Data Analysis Part 3 used an abductive analysis for explanation building. Explanation building is a technique used for explanatory case studies that allows for explaining a phenomenon through a set of casual sequences, enabling the exploration of the hows and/or the whys of that phenomenon [47]. Abductive analysis focuses on making a preliminary guess based on both the current theory being used and the data [55]. The explanation process of the relationship between the structural features and the partners' outcomes started by inferring from the results of the relevant characteristic structural features of each CSSP and the significant results on the partners' outcomes side. By doing so, it was possible to provide an explanation of why and how both levels were related and how the structural features had an impact on the outcomes that the partners gained by joining a CSSP. --- Results and Discussion --- Qualitative Study 4.1.1. Barcelona + Sustainable Barcelona is in Catalonia, Spain, with a population of approximately 1.6 million people. The CSSP of Barcelona, namely, B + S, has been working for the city's sustainability for about 17 years, with 1305 partners in 2019. This large CSSP consists of partners from all three sectors; the majority are civil society organizations and private sector businesses, with minimal participation from public sector entities. It is important to mention that a large number of public schools are members of B + S with a specific role in sustainability education, and thus, they were not included in this study. In such a large partnership, the communication system in place is a reflection of its complexity. It has both electronic and hard-copy newsletter formats that are delivered to the partners two times per month. It also has an ongoing website and a digital map. The digital map is a tool where not only partners but also the residents of Barcelona can find sustainability initiatives, pictures of places in the city, activities related to sustainability, etc. B + S also has regular meetings and social events with its partners, communicates through email daily if needed, and has an annual gala where the partnership reports progress on its goals. Workshops are led by B + S, and each sector runs its own workshops. Regarding monitoring and reporting, B + S reports about activities on an annual basis, including its projects. The evaluation of the progress on the partnership's goals is done every 10 years, which is the timeframe of every plan and plan renewal. They do not report or evaluate the partners' goals and outcomes due to the number of organizations participating in this CSSP. In terms of partners' engagement, there are two categories: partners' commitment and how new partners are being added to B + S. B + S's partners commit to the CSSP through endeavors that they decide to follow during their participation, which are very flexible. The B + S coordinator mentioned that the commitments could range from reporting their actions to making their own action plan that aligns with the goals of B + S. As the CSSP has many partners already, there is no need for B + S to recruit new members. However, the mechanism to attract new partners is by providing information through activities, resources and working on the partnership's goals so that other organizations can see what the CSSP is doing. Most of the people in the city know about B + S, and thus, the CSSP does not need to advertise for partners' engagement. New partners can join at any time. Regarding plan renewal, B + S's latest sustainability plan went from 2012 to 2022 following a previous one from 2002 to 2012. However, the renewal of the plan began in 2020 since Barcelona declared a climate emergency on 1 January 2020, and the climate emergency committee stated the necessity of implementing a 2020-2025 and a 2026-2030 climate action plan in order to meet carbon neutrality by 2050. This climate action plan falls under the larger B + S and replaces the 2012-2022 plan. The coordination of B + S is based on a technical secretariat that has 16 people; it is hosted in the municipality of Barcelona and is funded by the municipal government. Each sector, i.e., civil society organizations, public and private sectors, has its own dedicated coordinator hours. In terms of the decision-making mechanism, there is a committee composed of 50 members that are elected by the signatories of the commitment. Each sector elects its own representatives. The City Council is also part of the committee. --- Gwangju Council for Sustainable Development Gwangju is located in South Korea with a population of about 1.5 million people. The Gwangju Council for Sustainable Development has been working for Gwangju's sustainability for 24 years, with 115 partners in 2019. From the three case studies, this CSSP had the least number of partners. From their active partners surveyed in 2017, the majority represented civil society organizations. The communication system developed by GCSD is similar to B + S. Some differences can be found in the frequency of newsletters; its e-newsletter is delivered once a month and the hard-copy newsletter twice per year. It also has ongoing meetings and a website. Emails are sent and social events occur every two months. GCSD runs workshops once per year, and if needed, they can run more. There is an annual gala where they report the outcomes of the CSSP. Their monitoring and reporting mechanisms are based on the CSSP's goals, which are reported every five years, along with annual projects that are reported and monitored every year. GCSD creates sustainability agendas every five years, which are based on an evaluation of the past agenda and the local situation of Gwangju; therefore, they can promote actual social change. The partners' engagements in place are closely connected with the plan renewal process. Two years before the implementation of a new plan, GCSD recruits new partners through the recommendation of existing council members. Once the partners decide to participate, they have to plan their actions linked with the GCSD's agendawhich is supported by the local government-so that they can contribute to the CSSP's sustainability goals. In terms of coordination, GCSD has a secretariat that is hosted in the Gwangju City Hall, and it is funded by the local government. Thirteen people work in the secretariat and make the coordination of the CSSP possible. Regarding the decision-making processes, GCSD has a steering committee with nine people who represent the Gwangju region. Under the steering committee, there are six committees that oversee policy, education, business, ecological environment, economic society and community. Lastly, partner organizations are involved in decision making through their involvement in the 5-year agenda, which means that each year, partner organizations develop a project plan and participate in the decisions of that plan. --- Sustainable Montreal Montreal is located in Quebec, Canada, with a population of about 1.6 million people. Montreal's sustainability initiatives have been led by SM for 25 years, with 230 partners in 2017. From the active partners that were surveyed, it is possible to see that there was a more even percentage for each sector in comparison with the other CSSPs: 40% of the partners were from civil society, 27% belonged to the private sector and 33% of the partners were from the public sector. In Sustainable Montreal, the communication system in place is different from those of the other two CSSPs in terms of formats and frequency. Partners communicate through emails when needed, and on the Ville de Montreal website, there is a partner portal that partners can access. SM has an annual gala, where it reports the CSSP's goals and the partners' accomplishments. Compared with the other CSSPs, SM is the only one that reports about its partners' commitments and accomplishments. Both outcomes, i.e., the CSSPs' and the partners', are reported every two years. SM is on its third sustainability community plan, and in 2020, it was in the process of developing a new plan. Every time the city adopts a new sustainability community plan, there is a renewed commitment with the partner organizations. SM's partners are in charge of carrying out and endeavoring to align with the CSSP's sustainability plan. The partner engagement mechanism to add new partners is based on the adoption of a new plan; they reach out to the organizations they have targeted regarding the similarity of the organization's actions to the CSSP's goals. The recruitment is also conducted through networking events and by disseminating information. Regarding the coordination of SM, six people work in the Bureau du Développement Durable. For the CSSP itself, there are four mobilization teams that are aligned with Montreal's four sustainable development challenges, which are low-carbon Montreal, green city, neighborhoods that are great places to live in, and a prosperous and responsible city. The mobilization teams have one elected person, one administrator, and one citizen, plus the partners. Moreover, the secretariat is the coordinator for the mobilization teams. In terms of decision making, there is a coordination committee that includes people from the partner organizations, the central services and the mobilization teams. The participation of the partner organizations in the plan formulation decision-making processes is based on ideas they share regarding actions they want to happen for the plan. --- Quantitative Study Through a Kruskal-Wallis test, it was possible to show statistically whether the differences in how partners valued their achieved outcomes were significant among the three CSSPs. The results show that with a 95% confidence interval, there were significant differences in the value that partner organizations gave to community capital and physical capital . SM valued community capital more than B + S and GCSD, and GCSD valued physical capital less than B + S and SM. Pairwise testing using Dunn's test indicated that the value assigned by SM to community capital significantly differed from that assigned by GCSD , and it marginally differed between SM and B + S . For physical capital, the results indicate that the difference between the values assigned between GCSD and B + S and GCSD and SM were statistically significant. When comparing the values that partner organizations representing different sectors of society give to their achieved outcomes by CSSP, it was possible to see differences in the results. The Kruskal-Wallis test for B + S showed that the most valuable outcome by its partners was human capital , followed by community , organizational , physical and financial capitals . When comparing the values of each capital by the sectors that were part of B + S, the differences in the means were not statistically significant. In other words, there were no differences between the value that each sector gave to each capital. Nevertheless, there were marginal differences in the value that partners gave to financial capital in B + S. With a 90% confidence interval, the public sector valued the outcomes of financial capital less than the private sector and the civil society organizations in B + S. Similar to B + S, the Kruskal-Wallis test for the partners of GCSD showed that they valued human capital the most , followed by organizational , community , financial and physical capitals . The Kruskal-Wallis test showed that in SM the most valuable outcome was community capital , followed by human , organizational , financial and physical capitals . However, in both partnerships, there were no significant differences in the values that their partner organizations by sector gave to the outcomes they had achieved. Therefore, in these two CSSPs, partner organizations, regardless of the sector they represent, did not differently value the five types of outcomes being studied. --- Explanation Building Study --- Barcelona + Sustainable and Partners' Outcomes The statistical results for the partners of B + S indicate that public sector organizations gave less value to financial capital than private sector and civil society partners. These results were not the same for GCSD and SM; significant differences in the value that public sector organizations gave to financial capital were not found in these CSSPs. Therefore, what was different in B + S with respect to the other CSSPs that made its public sector partners value financial capital less than organizations from other sectors? When delving into the structural features of all the CSSPs, it was possible to notice that the composition of B + S was different from the other CSSPs. Out of the total number of B + S partners, only 7% belonged to the public sector, while in GCSD and SM, the percentages from the public sector were 19% and 33%, respectively, showing a clear difference in the number of public sector partners in B + S in comparison with the other CSSPs. Details in the database of partners' outcomes show that the public sector partners in B + S were universities, the board of libraries in Barcelona and a park. Most of these organizations receive public funding, among other types of resources. Moreover, the index of financial capital was measured through seven items: improving financial performance, reducing costs, funding opportunities, developing new products/services, making new business, attracting new investors and increasing financial resources. This suggests that these organizations did not see financial capital as a valuable outcome since their own financial system was strong enough to not necessarily value that outcome. Meanwhile, the private sector and civil society organizations did value this outcome more when participating in B + S. This could be explained by the place and institutional context of how these public institutions were funded compared with other country contexts. Table 5 details the partnership structure for B + S, along with the significantly different partner outcomes. 6 details the partnership structure for GCSD, along with the significantly different partner outcomes. The Kruskal-Wallis test for partners' outcomes on physical capital showed that the partners of GCSD valued that type of outcome less than the partners of the other CSSPs. Similar processes as used in B + S were followed to understand what was different in GCSD that made its partners value physical capital less. Comparing GCSD's structural features with the structural features of the other CSSPs, it was possible to notice that the partners' engagement, in particular the commitment of the partners, was different from those used in B + S and SM. In B + S, partners had the leeway to choose any type of action that they wanted to adopt, from reporting actions to implementing a sustainability action plan. In SM, partners had to adopt at least 10 actions from the sustainability plan. But in GCSD, partners were not asked to implement actions in their organizations; in contrast, they collectively implemented actions to contribute to the sustainability of Gwangju. Therefore, the rest of the structural features seemed not to allow their partners to improve their resources and processes. Perhaps local culture influenced the design in Gwangju, which was only implemented through community actions and not internal organizational actions. 7 details the partnership structure for SM, along with the significantly different partner outcomes. The descriptive results for the partners' outcomes, and in particular, for community capital, show that this type of outcome was the most valued by the partners of the three CSSPs. However, the Kruskal-Wallis test for community capital indicated that the partners of SM valued community capital more than the partner organizations participating in the other CSSPs. Community capital was measured using five items that focused on contributing to the sustainability goals of the vision, environmental challenges, social challenges and the sustainability of the community. These results suggest that if all the partners value community capital the most, what was different in Sustainable Montreal that made it possible to find significant differences in them? While comparing the structural features of the CSSPs, it was possible to notice that the partners' engagement in SM was stronger than in the other two CSSPs. The commitment of the partners was based on adopting 10 actions from Montreal's sustainability plan, which ensured the partners were aligned with the local plan completely. As the partnership's goals and the partners' actions were aligned, monitoring and reporting the outcomes of the partners became easier, and therefore, partners could have accountability, not only from their organizations but also from the CSSP about their own goals. When it came to decision-making mechanisms, as the partners were implementing the actions of the sustainability plan, they had a say in the decision making regarding the types of actions they wanted to see happen in the sustainability plan. This configuration did not happen in the other CSSPs, which suggests why, despite the fact that all the partners from every CSSP did value community capital, the partners of SM valued it more. The main differences occurred in terms of three key structural features that were stronger in comparison with the other CSSPs. --- Conclusions The aim of this research was to understand the structural features of large CSSPs and the partner outcomes during the implementation of sustainability community plans. The main contributions were related to the structural features of large sustainability partnerships and the relative similarity of partner outcomes from large CSSPs, regardless of sector. This research offers a framework of seven structural features that were considered to be key within the CSSPs: communication systems, monitoring and reporting, partners' engagement, renewal systems, coordination, decision-making processes and the composition of the partnership. Some of these structural features were offered before within the collaborative strategic management literature; however, they were not sufficiently studied and developed in the context of large CSSPs. The results suggest that the most distinguishing structural features that differed between the three cases were monitoring and reporting, in particular, whether these were focused on the partners' activities; partners' engagement, in particular, whether partners are actively implementing the collaborative strategy; and the composition of the partnership, in particular, the predominance of the sector. The other features of communication systems, decision-making systems, renewal systems and coordination were also important structural features for achieving the partnership's goals and for having a better understanding of the partners' outcomes, and they had considerable similarities between the three cases. However, the analysis presented here focused on differences between partnerships, and as these structural features were relatively similar, they did not appear to be linked to the differences in partner outcomes. The empirical results on the partners' outcomes show that there were almost no differences found in the value given by partner organizations to outcomes that could be relevant for them regarding the sector they represented. The extended RBV literature offers five types of outcomes: community, organizational, physical, financial and organizational capitals [1,12,14]. The literature states that the types of outcomes that partners can obtain from joining a partnership are related to the sector to which they belong [1,15,56]. However, except for the results found for Barcelona + Sustainable, where the public sector rated financial capital the lowest valued, partner organizations did not give more value to the types of outcomes based on the sector to which they belonged. Through understanding these large CSSPs and their partners' outcomes, we aimed to contribute to the success of partnerships and, in particular, to how partnerships can help their partners achieve their organizational goals. The studied partnerships have been operating for many years with a high number of partners from across sectors, and thus, their experience and the relationships they have developed are a good learning experience for other partnerships to consider. However, understanding that success and impact are dimensions that are understudied in the partnerships research [57], this research also opens room for further research on the contributions that large partnerships make toward their collaborative goals and to their partners' sustainability outcomes, and what difference the structural features make in achieving that progress. --- Data Availability Statement: Data available on request due to restrictions. --- --- Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

The aim of this research was to understand the structural features of large cross-sector social partnerships (CSSPs) and their resulting partner outcomes. This study analyzed and compared the partnership structures of three large CSSPs, each from a different continent: Barcelona + Sustainable in Barcelona, Spain; Gwangju Council for Sustainable Development in Gwangju, South Korea; and Sustainable Montreal in Montreal, Canada. Based on a survey of the partners in each of the three partnerships, the partner outcomes were also determined and compared. Building on these findings and using abductive analysis, the relationships between the partnerships' structural features and partner outcomes are considered. An updated set of seven structural features for studying large cross-sector partnerships is offered. The empirical findings show some differences between the partnership designs and between the partner outcomes of the three partnerships. The experiences of the civil society, private sector and public sector partners in each of the cases were relatively similar, showing that in large partnerships, the sector was less relevant than in small partnerships.

Introduction Kgatla holds a firm belief that the church's efforts to convert black individuals in Africa to Christianity through missionary work have had unintended negative consequences on social interactions and justice in the region. He proceeds to assert that certain regions have experienced a distortion of holy Scripture pertaining to fundamental human relations and social justice as a result of the Christian Crusades, civilization, and colonisation of African people . The colonial perspective of the entitlement to conquer and appropriate land from individuals of African descent resulted in a deviation from the fundamental principles of Christianity, which emphasise the importance of adhering to Christ's teachings of love and fostering positive relationships with one's neighbours. Kgatla's argument is founded upon the work of Johnson , who posited that the perception of Africa as the pinnacle of human development in South Africa was due to the prevalence of white racial supremacy and control over black individuals. Consequently, the pursuit of social justice in this context resulted in more negative outcomes than positive ones. The prevailing understanding and maintenance of Christianity among the white population in South Africa during the apartheid period did not align with the principles of social justice and coexistence. The individual's religious beliefs involved abstaining from involvement in political matters and deferring to the governing party, with a focus on spiritual pursuits that would lead to salvation . A variant of Christian theology centred on escapism was formulated, with the backing of white piety and global Pentecostalism, which pledged redemption devoid of concerns for social equity. However, in our attempt to assist the church in her missional task of holistic diaconia, we have found that the colonial irony is still predominant in various congregations . The colonial mentality was, 'we do to you and we do for you because we know what is best for you'; however, we believe that a colonial indoctrination happened within the mindset of many ministers. Hence the irony, although we are today very critical of colonialism, many of our colleagues in the church ministry and in their understanding of diaconia within the Uniting Reformed Church in Southern Africa , are still doing diaconia in a charity mode and with the 'colonial irony' of, 'we do to the poor and we do for the poor because we know what is good for the poor' . This colonial irony limits us to move beyond a charity mode of diaconia as we are stuck in short-term projects and handouts such as soup kitchens, food parcels, and clothes banks. Although these charity mode services remain important to address the immediate need, in order to move to a more sophisticated mode of development, we propose in this article that perhaps we should redefine our understanding of diaconia through the lens of a social justice approach. Hence, it is our perspective that the historical impact of the apartheid regime is a crucial element to consider when examining contemporary social inequities in South Africa. The South African government has identified unemployment, poverty, and social injustice as the primary challenges that must be addressed to foster a robust nation. However, thus far, government efforts to tackle social injustices in post-apartheid South Africa have primarily centred on political and civil rights, while the socio-economic needs of a significant portion of the country's impoverished and marginalised population have remained unfulfilled. This article highlights the correlation between social injustice and poverty, emphasising the profound impact that poverty and unemployment have on human dignity. Simultaneously, it is imperative to acknowledge that the act of excluding individuals from poverty and unemployment alleviation practises is a transgression of dignity. Thus, the goal of sustained poverty reduction and sustainable development cannot be achieved unless social justice is emphasised. Of course, we can hold the government accountable for this situation but we should also renew our understanding because the authority is often fragmented and involves non-governmental role players such as faith leaders, which is an important lesson to learn from development praxis according to Gaventa and Oswald . The church, being closer to the reality of people and communities, is called within this context to be true to her missional calling of doing diaconia. But how do we move beyond mere 'hand-outs' 'project mode' to transformational differences as a church? How can we consciously strive towards strengthening the agency role of people from poor communities as a church with a diaconal task? We propose that the social justice theories should be used as a lens to assist us in making this shift within our understanding of diaconia in South Africa. The purpose of this article is to explore specific justice theories, feeding and leading to a social justice approach in development. The objective of this article is to analyse various aspects, including: A concise overview of the socio-economic and socio-political context of South Africa; a call for action in the form of diaconia and social justice; A justification for adopting a social justice approach; An evaluation of selected social justice theories; A proposed approach for implementing social justice in practise. Finally, the article concludes with deductions drawn from the proposed praxis for social justice. The present argument posits that by adopting the aforementioned identification, the social justice approach will strive to ensure equitable treatment of individuals and collectives, alongside equal access to services, their availability, and opportunities for growth and progress. --- A Socio-Economic and Socio-Political South African Context In present-day South Africa, analysts are directing focus towards the resurgence of outrage among impoverished black communities, reminiscent of the apartheid era, as they engage in increasingly aggressive demonstrations against their substandard living conditions and apparent lack of municipal service provision . In a manner comparable to the era of apartheid, there is a resurgence of nationwide unrest that prompts significant inquiries regarding the condition of democratic governance in presentday South Africa. Protests are being carried out by impoverished communities due to their discontentment . Instead of positing a singular cause, a nexus of interconnected causes can be discerned to account for this collective fury, specifically elucidating why a significant number of the nation's most impoverished communities are agitated and thus engaging in protests that have escalated to violence. While the notion remains disputed in the discourse surrounding service delivery, it has been claimed that the community's discontent may have stemmed from a feeling of 'relative deprivation' among its constituents . This unequal service delivery and unequal access to other services in poor communities created anger as there existed a disparity in the provision of infrastructure and services between the impoverished areas and other regions of the city, with the former receiving subpar amenities. Moreover, in contemporary South Africa, a total of 26 million of the nation's 55 million inhabitants are presently residing below the poverty threshold of USD 2 per day. Harold asserts that the majority of black South Africans, and Africans in general, experience significant disadvantages in comparison to their white South African counterparts. The proportion of African adults holding a tertiary qualification is 4%, while the corresponding figure for white South Africans is 25%. In the South African economy, the proportion of white individuals occupying top managerial positions is 70%, while 59% of senior managers are also white. The unemployment rate for individuals of African descent stands at 28.8%, while for those of white ethnicity, it is 5.9%. The data indicate that a significantly higher proportion of white South Africans, approximately 61%, reside in households that have a monthly expenditure exceeding ZAR 10,000, whereas only a mere 8% of Africans have the financial capacity to spend the same amount. According to statistical data, a significant proportion of the African population, approximately 16%, experience extreme poverty and frequent hunger. In contrast, a vast majority of white South Africans, approximately 99.9%, enjoy a higher standard of living . The aspiration for peaceful coexistence among South Africans is being challenged by the lingering effects of apartheid, resulting in animosity and an escalation of demonstrations in recent years and months . These protests might not be ideal but it obliges us to broaden our understanding of agency and how it contributes to empowerment and accountability, which is an important lesson to learn from development praxis . The church's response must be situated within this particular context. Rather than leading an ascetic lifestyle and disengaging from the world, the church should actively involve itself in the struggles of the majority in post-apartheid South Africa. This can be achieved by aligning its words and actions with those of the marginalised and voiceless, thereby serving as a prophetic conscience to both the government and the community at large. In the context of post-apartheid South Africa, the church can serve as an alternative community that fosters the growth and development of individuals. To achieve this, it is imperative for the church to acknowledge and reinforce the shared humanity that binds people together . This necessitates proactive attention to justice and the welfare of society, arising from a sense of solidarity with the rights and needs of fellow individuals. Thus, solidarity is considered a virtue that motivates the church to take action, rather than a fixed state of being or objective . --- A Call for Action: Diaconia and Social Justice In the past two decades, a significant change in paradigms has occurred, resulting from both political and social advancements. The United Nations "Convention on the Rights of Persons with Disabilities" has resulted in the adoption of an inclusion paradigm in both theoretical and practical contexts. The concept of inclusion pertains to a societal structure that does not involve the marginalisation of individuals. It envisions a scenario where individuals with varying abilities are visibly and tangibly integrated into the wider society, actively participating and connected to the overarching goals and objectives. The trend towards inclusivity entails a dual emphasis, namely, a focus on the individual as well as on the community. To enhance the involvement and self-governance of individuals, it is imperative to take the dynamics of a community into account. This entails exploring ways in which individuals can mutually empower and enhance each other, as well as how various entities and actors can provide distinct forms of support to enable individuals to lead self-sufficient and self-directed lives . Swart argues that the practical and applied discipline of diaconia is currently facing a significant challenge to its identity. This challenge is being shaped by the concept of a 'new paradigm of diaconia', which represents a distinct shift in the way that theorists of diaconia approach their work. Specifically, there is a growing awareness of the need to move away from traditional conceptualisations of diaconia as a form of humble service or paternalistic charity. Instead, there is a renewed emphasis on relating to those in need of assistance in a way that fully respects their humanity and agency as independent subjects. Thus, with regard to the objective of formulating the concept of diaconal practice, this implies that... those who are providing help or offering diaconal service should do so in a way of respecting the autonomy and integrity of the other, and avoid creating relationships shaped by uneven dependencies. This principle is relevant both at an interpersonal level, for instance, when providing financial support to individuals, and at a more structural level, as in international aid, where longstanding relationships of dependency should be avoided. Thus, diaconal service should focus on reducing dependencies, supporting independence, and activating the other person's own resources to cope on their own in the long run. Autonomy and interdependence are not opposites but are related to each other dialectically and complementarily. . This encouragement for a paradigm shift by both Swart and Dietrich reassures us that social justice values should be taken seriously in this endeavour of understanding diaconia in a holistic sense rather than mere charity and humble service. Poverty is widely recognised as a tangible illustration of the potential infringement of dignity within social contexts. The concept of human dignity pertains to the right of an individual to be recognised as an autonomous being who possesses the freedom to pursue their own beliefs and values, thereby leading a life characterised by self-esteem. The reliance of impoverished individuals on external sources for sustenance and support undermines their capacity to assert themselves and engage with others as autonomous agents, thereby impeding their ability to pursue self-determined lives. This dynamic transgresses their inherent sense of self-worth and, by extension, their dignity. The resolution of such instances of transgression can solely be achieved through the provision of alternatives to individuals residing in impoverished conditions, and when their subsistence is not entirely subject to the discretion of external agents. This would imply that individuals not only possess the material resources required but also possess the necessary abilities or capabilities to facilitate the actualization of various options. Fundamentally, diaconal labour involves addressing the concept of "otherness", which pertains to individuals who are distinguished as distinct within societies due to factors such as gender, ethnicity, social and economic standing, physical and mental capabilities, age, and other similar characteristics. The concept of "New Diaconal Professionalism" pertains to the management of otherness in the realm of professional social work and theology, in response to emerging challenges, particularly those related to inclusivity . Hence, we will turn our focus on the social justice approach as a manner to reshape diaconia in our South African context. --- A Rationale for a Social Justice Approach This article acknowledges that there is a close correlation between social justice, diaconia, and human rights. The purpose of this article is not to duplicate the extensive scholarly discussions pertaining to the concept of social justice. The emphasis lies on the application and practical implementation of the concept as a framework for diaconia and community development. Social justice is multifaceted and therefore there is a need to identify key concepts underpinning social justice which is required for critical engagement in the implementation of diaconia as well as community development. The theme of social justice is present throughout the entirety of the Bible, spanning from the book of Genesis to the book of Revelation. According to Crossway , there are 69 scriptural portions in the 69 books of the Bible that contain a direct appeal to social justice. This concept underscores the shared ancestry and ultimate fate of the human race . The Bible's primary message is underpinned by God's summons for social justice, grounded in the shared origin of humanity and the divine intention for their existence. It has been ordained that certain responsibilities are attributed to the human race. The original divine plan was for humanity to coexist in concordance with the laws and purposes of God . Humans were appointed as representatives of God on earth to carry out his justice. Moreover, from a biblical or theological standpoint, comprehending justice within the framework of the covenant, wherein each covenant member is bound to demonstrate love towards God and their fellow human beings, proves to be a valuable perspective. Moreover, justice is an ethical concept that pertains to individuals who exhibit generosity within their community with the aim of fostering, maintaining, and augmenting the community's welfare. The term 'who' refers to an individual who is recognised for actively engaging in community investment, and displaying exceptional care and attention towards individuals who are impoverished, vulnerable, or in need. The prophets have provided a comprehensive outline of a communitarian ethic . Regrettably, the Israelites, who were selected as a model by God, misconstrued their election through Abraham and their departure from Egypt, along with the accompanying benefits and entitlements, as their individual prerogative that ought to be exclusively exercised by the Jewish people. According to Leviticus 19:18, the term "neighbour" was interpreted by the people of that time to refer to their "associate". As a result, the Jewish community defined a neighbour as an individual who belonged to their collective group. It was incumbent upon the Israelites to treat individuals of this nature with equity and benevolence, refraining from engaging in any form of deceit or theft. However, the Jewish community's treatment of individuals who were not of Jewish descent was such that they did not regard them as being of the same status as Jewish individuals. Jesus arrived with the intention of altering this viewpoint. Among the four authors of the Gospel, namely Matthew, Mark, Luke, and John, Luke's account is particularly lucid in its portrayal of Jesus' aim to rectify erroneous Jewish notions regarding the concept of neighbour. In contrast to the Jewish belief that social justice should only be extended to their own community, Jesus challenged this notion and advocated for the inclusion of both kin and non-kin as deserving recipients of social justice. He emphasised the importance of treating strangers with the same level of care and consideration as one's own family members . In general, human beings are inherently social creatures, and their lives are significantly shaped and influenced by their social interactions and relationships. On an individ-ual basis, people have the ability to either positively or negatively impact the development and dismantling of their respective organisations. The coexistence of human beings is a collective experience, wherein interdependence on fellow individuals is a crucial aspect of survival . Therefore, social relationships and institutions serve as the fundamental basis upon which human existence is established and maintained. Within any given society or organization, there exists a power dynamic that serves to either limit or facilitate the actions of individuals. The presence of checks and balances within an organisation can facilitate the equitable distribution of opportunities for all members to contribute to its overall welfare, provided that corrective measures are implemented in a just and impartial manner. The institution of the church is founded upon the fundamental principles of social relations . The promotion of human rights for all members of society is a fundamental principle of community work, which is underpinned by the concept of social justice. The attainment of social justice entails the recognition and endeavour to mitigate systemic hindrances, prejudicial treatment, and disparity. According to Fraser's analysis, there exist two primary methods of addressing social justice. The initial perspective centres on the equitable allocation of resources and commodities, whereas the latter perspective centres on the politics of acknowledgement. According to Fraser's argument, instead of separating the two aspects of justice, it is imperative to consider and tackle both of them. Lister argues for the integration of redistribution and recognition, contending that this approach enables policy demands that lead to equitable representation and adequate social security to support a dignified standard of living. The pursuit of recognition is an everyday occurrence in various strata of society and can be demonstrated across multiple tiers. Unequal access to resources such as income, job opportunities, schooling, and medical services can result in a dearth of political and policy recognition. The recognition of voice and identity is imperative, encompassing the acknowledgement of diverse identities and the re-evaluation of undervalued, marginalised, or overlooked identities. The act of recognition should not be superficial or symbolic, but rather should actively facilitate opportunities for expression, participation, and authentic incorporation. The absence of acknowledgement is frequently linked and intensified in instances of economic disadvantage. According to Taylor's proposal, the formation of identity and expectations of individuals and groups is influenced by recognition, and the lack of it can result in significant adverse consequences. Authentic Christian justice based on biblical principles is firmly rooted in the compassionate nature of God. The individual maintains that the deity possesses a distinct concern for the well-being of individuals situated at the lowest rungs of the societal hierarchy, such as orphans, widows, and other legal immigrants, residents of impoverished neighbourhoods, and other marginalised or alienated groups. If the church acknowledges this matter, it ought to take the lead globally in pursuing social justice by establishing a clear definition of social justice, identifying fundamental biblical principles of social justice, and formulating a robust stance on any measures taken to address current social issues . Social justice in the South African context can only be fully comprehended when approached from a holistic perspective, taking into account the country's complex historical and colonial legacy. The correlation between unemployment and the quality of school education for historically marginalised individuals, substandard and restrictive infrastructure, and subsequent occurrences of corruption, favouritism, familial biases , and a sense of entitlement should be comprehended. Chipkin posits that social justice is achieved through the establishment of justifiable relationships between social classes and groups, which are based on a fair distribution of public and private goods and benefits associated with national and economic growth. Altmann provides a definition of social justice in his speech to the tenth assembly of the World Council of Churches , characterising it as a shared journey towards a collective fate. The WCC has articulated its definition of social justice in a public statement, which involves the pursuit of the common good through the identification and confrontation of privilege, economic injustices, political and ecological exploitations, and oppressive forces that exploit marginalised individuals and communities. Social justice refers to the ability to collaborate with others and achieve goals that are advantageous to the entire community . The concept of social justice pertains to the equitable preservation of access to rights and opportunities, as well as the provision of care for the most vulnerable members of a given society . Rawls posits that the determination of justice or injustice is contingent upon its ability to facilitate or impede equal access to civil liberties, human rights, opportunities for health and fulfilling lives, as well as the equitable distribution of benefits to the most disadvantaged members of society. The notion of social justice employed in this context of diaconal and community development endeavours to tackle and emphasise the comprehensive and inclusive rights of communities and their members, while simultaneously acknowledging that the rights each person has should not be invalidated or disregarded by the collective. Fraser's conceptualisation of social justice posits that in order to achieve justice, it is necessary for collectives to attain both recognition-based justice and economic distribution-based justice. The practical question that arises from this two-fold understanding of social justice is how to effectively engage groups in this pursuit. --- Theories of Social Justice In relation to the aforementioned section, the pursuit of social justice is rooted in the fundamental premise that all individuals are created in the image of God and, as such, possess inherent worth. With regard to the biblical foundation of social justice, it can be argued that individuals possess a moral obligation to assist those who are marginalised within their community. The principle of love, as prescribed by Christian doctrine, mandates the provision of care to individuals in need, irrespective of their nationality or relational proximity. The aim of social justice is to rectify instances of inequity and promote parity in the distribution of resources and assets. On 26 November 2007, the United Nations acknowledged the necessity of advancing endeavours to address concerns such as destitution, marginalisation, and unemployment. Consequently, the UN resolved to commemorate February 20th every year, commencing in 2009, as the World Day of Social Justice . 1 The Italian Catholic cleric and scholar Luigi Taparelli coined the phrase social justice in the 1840s. He used it to define the fundamental principles of a just society as well as how advantages and responsibilities are shared in a community . Numerous theories and methodologies have evolved over the course of the 20th century, each of which has its own meanings, principles, and consequences for the idea of social justice. Each of these uses a distinct data basis of reasoning to make decisions about the suitability and fairness of various social circumstances by including and excluding pertinent information . Therefore, it is crucial to weigh the benefits and drawbacks of the informational foundations of some of the key theories of social justice, including the Utilitarian perspective, John Rawls' Theory of Justice, Sen's Capability Approach, and Nancy Fraser's Theory of Social Justice, in order to comprehend the complexity of social justice and incorporate its principles in development. --- The Utilitarian Perspective The Utilitarian viewpoint, which held sway as the preeminent doctrine of justice for more than a century, prioritised the aggregate 'utility' of an individual. The concept of "utility" pertains to the quantification or evaluation of an individual's happiness or pleasure. This viewpoint posits that the sole desirable entity is happiness . The state of happiness is considered a self-sufficient objective, whereas all other things are regarded as instruments or pathways towards achieving that objective . This perspective emphasises the need to judge the consequences of all choices. Choices are right if they promote happiness and wrong if they do not promote happiness. Therefore, it is imperative to evaluate every institution, law, or action based on the level of happiness it produces . Ultimately, happiness is good as in the final analysis, the state of being happy is considered to be beneficial. Thus, this viewpoint advocates for the advancement of the common good that benefits a larger population. However, this is not only for a greater number of people but ideally inclusive of all people as indicated by Bentham's view on utilitarianism . --- John Rawls's Theory of Justice The Theory of Justice by John Rawls is widely regarded as an influential concept of justice in the 20th century. Rawls's theory of justice is primarily grounded in the notion of fairness . The concept of justice as fairness posits that the principles of justice that are most rational are those that would be mutually agreed upon by individuals under equitable circumstances, with the aim of achieving fairness. Fairness can be defined as the antithesis of unfairness, pertaining to connections that facilitate, transform, and empower simultaneously. Therefore, the implementation of social justice necessitates sound decision-making skills from individuals in positions of power and authority. The very first principle posits that there should be an equitable distribution of all social primary goods among all individuals . The second principle pertains to the equitable allocation of social primary goods, wherein any departure from parity ought to be advantageous to those who are least privileged . While the Utilitarian school of thought prioritised utilities, Rawls argued for the significance of social primary goods. The author posited that primary goods are the necessary means that an individual is presumed to desire in order to advance their objectives. These primary goods encompass elements such as income and wealth, basic liberties, freedom of movement, and self-respect . Moreover, it is suggested that rather than concentrating on a single principle, such as utility, the prioritisation of social goods should be arranged in a lexical sequence of equivalent importance, namely, liberty, necessity, and utility . --- Sen's Capability Approach Sen's scholarly work introduces the concept of the 'capability approach', which centres on the correlation between individuals' resources and their capacity to utilise said resources . The objective of the capability approach to social justice is not limited to the identification of individuals' functioning. Instead, it aims to consider the degree of freedom that individuals possess to achieve this functioning and to establish circumstances that enable all individuals to enhance their freedoms and experience comparable capabilities. For instance, this approach would consider the capabilities of a fasting man and a destitute person . Sen expresses hesitancy towards endorsing a universal set of capabilities that would serve as a baseline standard for all societies. However, he does outline five political freedoms that he deems instrumental in contributing to people's overall freedom to live their lives as they desire. These freedoms include civil and political rights, economic facilities that provide opportunities for the production or exchange of economic resources, social opportunities that encompass both public services and private facilities, transparency guarantees to prevent corruption and financial irresponsibility, and protective security measures that ensure social security . Sen has made significant contributions to the field of social justice by establishing connections between the public and private spheres of society. In the past, scholars in the field of social justice overlooked the significance of private inequalities, specifically those related to gender, in the attainment of social justice . --- Nancy Fraser's Social Justice Theory The application of social justice in the realm of community development endeavours to tackle and prioritise the comprehensive entitlements of groups and communities, while concurrently acknowledging that the interests of individual members should not be disregarded by the collective. Nancy Fraser is a renowned contemporary American political philosopher whose fundamental principle of justice is centred on the concept of participation equality. Fraser argues that collectives must strive to achieve both recognition justice and economic distribution justice. Thus, the concept of justice necessitates the establishment of societal structures that facilitate equitable peer interaction among all constituents and an even allocation of tangible assets . Fraser's framework for justice comprises three dimensions, namely, redistribution, recognition, and representation. The concept of redistribution entails the notion of equitable allocation of resources, a principle that bears resemblance to the ideas espoused by scholars such as John Rawls . The objective of recognition is to emancipate individuals or collectives from the inferior position in social culture and to guarantee equivalent cultural status and identity for every member of society. Regarding the political aspect of justice, the concepts of redistribution and recognition extend beyond nation-states within the framework of globalisation. Hence, the political facet of representation can solely furnish mechanisms for resolving issues by determining the eligibility of individuals to partake in communal existence as a constituent. Political representation encompasses both symbolic framing and political voice . Achieving equality of participation necessitates the equitable allocation of material resources, irrespective of the varying characteristics of participants such as gender, race, and other attributes. Fraser contributes to the theory of justice by speaking to the struggle for equitable distribution, but this view has been challenged. Robeyns contends that Fraser fails to acknowledge the distinctions among various theories of distributive justice. The individual posits that the assessment of Rawls' theory appears to be overly simplistic and is not applicable to Sen's capability approach . Therefore, redistribution must be redefined to include the main ideas of theorists like Rawls and Sen. The principle underlying justice ought to be that of equal participation with the inclusion of the dimensions of redistribution, recognition, and representation. Fraser formulates a theory of global justice by incorporating the element of representation. This dimension prioritises the inclusion of the general populace over political elites, thereby offering fresh insights and avenues for research aimed at addressing the challenges inherent in contemporary global justice systems . Fraser posits that her theory of justice should be grounded on the principle of participation equality, whereas Forst suggests that addressing issues of domination and unjustifiable arbitrary decisions can be achieved through redistribution, recognition, and justification because the distribution of certain goods is not mandated by the fundamental principles of justice. In addition, Gaventa warns that although there are increasing prospects for civic participation in policy-making procedures, it is evident that the mere establishment of novel institutional frameworks may not inevitably lead to amplified incorporation or policy modifications that are favourable to the impoverished. Rather, the efficacy of these new, conceivably more democratic domains is heavily contingent upon the character of the power dynamics that envelop them. However, Fraser continues to make equal participation more applicable through practical methods to recognize the uniqueness of participants, diversity, common humanity, and complexity of the forms of wrong recognition . Having mentioned that, we agree with Fraser's normative foundation of equal participation and concur with Parfitt that depending on how participation is implemented, it may be perceived as a method of pursuing conventional development objectives in a hierarchical manner while creating a deceptive impression of executing more comprehensive initiatives that aim to empower marginalised communities and individuals, but despite these risks, most definitions of participation share the view that involving and informing individuals in projects that impact them can lead to an improvement in development outcomes. --- A Proposed Praxis for Social Justice The utilisation of social justice by Ginwright and Cammarota has the potential to cultivate critical consciousness of the social context. Our argument is that the aforementioned approach should be combined with social action, which Freire refers to as "praxis". Social justice, as a facet of community development, entails promoting group introspection, analysing available alternatives, and subsequently implementing actions based on these reflections. Social justice pertains to addressing social and economic disparities while upholding human rights and enabling individuals to take action towards rectifying these inequalities. Thus, it necessitates a heightened awareness and capacity for action . How do we as a church utilise, embody, or praxis our rich sources such as the Accra 2 , Kairos 3 , and Belhar 4 confessions to enable transformation in our communities? The WARC has made efforts to implement practical applications of the confessions within its framework . A robust theoretical framework has been established on the basis of Accra and Belhar. What is currently required is a form of practical application or implementation. In essence, the task at hand involves establishing a structured system that can enable groups and associations to comprehend, discern, and contemplate the significance of acknowledgement, allocation, and portrayal. This system must also offer the necessary assistance to devise remedies and avenues for improved relationships, with the ultimate goal of remedying perceived inequities. Concepts that will assist us in our understanding and application to move beyond a charity mode/services/once-off projects to social justice are recognition, redistribution, representation, including key concepts like fairness, empowerment, compassion, equal participation, building of relationships, and holistic well-being. We will continue this article by first unpacking these concepts to enhance a praxis for social justice. --- Redistribution The living conditions of many South Africans reveal that poverty serves as the initial point of attack on the image of God. In South Africa, it is a prevailing fact that the demographic group most affected by poverty is the black population. The enduring economic impact of centuries of colonisation and oppression, which included limitations on mobility and social interactions, has had a significant and ongoing impact on the majority of black individuals in South Africa. Therefore, the church is tasked with a ministry that entails maintaining a delicate equilibrium between providing assistance and fostering growth. Development ministries aim to empower individuals who are unable to support themselves financially. When the church recognises its authentic identity as God's children, it rediscovers its genuine purpose by viewing itself as responsible and efficient caretakers of God, working towards the betterment of all . Essentially, development is about people and how to improve their quality of life. The level of satisfaction with fundamental human needs is a crucial determinant of an individual's quality of life . Therefore, Max-Neef proposes the "Human Scale Development" as a needs theory for development. He identifies a total of nine essential human needs which encompass subsistence, affection, protection, understanding, participation, identity, creation, leisure, and freedom. There exists no hierarchy of needs and none of the aforementioned needs is more important than the other. Unsatisfied needs are viewed as poverties and therefore he extends the concept of poverty to more than a lack of income which means that development is the reduction of different poverties. Furthermore, the means to satisfy these needs are by satisfiers including "being", "having", "doing", and "interacting", which in turn can result in different economic goods. These satisfiers are merely suggestions which are not conclusive but can vary depending on diverse cultures and historical moments . Due to the diverse nature of needs, transdisciplinary approaches should be adopted to operationalise development . In support of the United Nations Sustainable Development Goals , South Africa has aligned its vision to the SDGs and allocated a budget accordingly 5 . These goals are: no poverty; zero hunger; good health and wellbeing; quality education; gender equality; clean water and sanitation; affordable and clean energy; decent work and economic growth; industry, innovation, and infrastructure; reduced inequalities; sustainable cities and communities; responsible consumption and production; climate action; life below water; life on land; peace, justice and strong institutions; and partnership for the goals. However, based on various research works , it seems that South Africa is not successful in addressing the needs and reaching these goals of South Africans. Within these mentioned research works, it is evident that African people and specifically youths are viewed as a vulnerable and marginalised group within present-day society . Of a variety of contributing factors which cause marginalisation, the three main contributing factors identified are poverty, unemployment, and exclusion. This view is supported by various research findings and statistics related to young people being excluded from education, employment, and/or training opportunities . Other social issues that marginalise South African youths are reported to include a high drop-out rate in educational settings, inadequate skills development, inadequate youth work services, poor health, high HIV and AIDS prevalence, high rates of substance abuse, crime, and violence, a lack of access to sporting and cultural development opportunities, a lack of social cohesion and volunteerism, and disability and exclusion . In addition, based on our argument hitherto, we would like to use the Land Reform initiative as another example. Nancy Fraser's concept of redistribution can potentially serve as a means to prompt the government to accelerate its Land Reform initiative. Additionally, the 1913 Land Act in South Africa has been identified as having unfairly advantaged specific racial groups, and as a result, restorative measures are necessary to address the injustices inflicted upon those who were negatively impacted by this oppressive system. The act of redistribution or restitution is a crucial aspect of the process of reconciliation, as it entails relinquishing something that leads to a deeper comprehension of the affliction inflicted upon the majority by apartheid. It is arguable that this facet of the process is the most humane. When the church, as the collective body of individuals who belong to God, takes charge of this procedure, it does so from a standpoint of empathy. This kind of praxis will lead to empowerment as indicated by Chambers in . Empowerment means that people, especially poorer people, are enabled to take more control over their lives and secure a better livelihood with ownership and control of productive assets as one key element. Christens in Gaventa clarifies community power even further, arguing that empowerment refers to any positive development amongst group members or as the process by which groups attain increased authority over their situation. Linking themes of power and empowerment can be done by bringing together several prepositions which frequently accompany the word power such as power "over", "with", "to", "within", and "for" . In this analogy, "power over" denotes the ability of individuals or groups to exert influence and authority over others and "power to" refers to the ability to act and therefore suggests empowerment. These are frequently perceived as being in conflict with one another or as competing definitions but could be seen and used as being interrelated and unified whereby social action is a dynamic process in which marginalised groups cultivate a sense of agency and collective empowerment to contest external forces that exert control over their lives, thereby enabling them to attain greater autonomy and self-determination. The prevalence of power changes and therefore it is of utmost importance for a development practitioner to re-evaluate power relations continuously . --- Recognition The church is therefore tasked with the responsibility of manifesting the attributes of God as evidenced by its demonstrations of benevolence and affection. Hence, it is imperative to delve into the definition of compassion and its application in the context of South Africa. The South African church has the potential to embody the ideals of a benevolent, empathetic, and affectionate community, which serves as a model for other communities to emulate. According to Davies , the virtue of compassion necessitates a profound shift away from self-centredness and entails a willingness to jeopardise one's own comfort in order to empathetically experience the plight of those who are marginalised and in pain. The concept of compassion is rooted in acknowledging the inherent divinity of others as they are created in the likeness of the divine. The self undertakes the responsibility of the other due to this comprehension. According to Davies , the recognition of God's image in others, albeit veiled, leads to a better understanding of our own identity. According to Nouwen et al. , the term compassion denotes the act of "suffering with". Compassion, therefore, requires one to enter spaces where one identifies with the weak, vulnerable, and powerless. Compassion entails complete engagement with the state of humanity. Compassion is a complex emotion that transcends mere pity and is considered to be the most authentic manifestation of divinity in human form. The compassion of God is transferred onto us. The concept of self-denying or "kenotic love" as described by Davies has implications for various aspects of human existence and endeavours to facilitate the achievement of social cohesion. This extreme expression advocates for the recognition of one's own identity reflected in another individual. The church, as an alternative community, endeavours to recognise the divine image in all individuals within the society. What does it mean to be made in God's likeness , and how does that bring this deed of mercy into focus? This "image" is provided by God and is essential to human dignity because the forgiving, caring God is the fundamental religious problem in human dignity. As an alternative community, the church is compelled by this knowledge to voice out against the social, political, and fiscal obstacles that keep people apart. The church takes on the role of the prophetic voice that condemns poverty as a condition that compels people to live in a state of inadequacy and servitude in relation to those who must continue to be their dependencies and masters. The church allows us to engage with and inquire about the One who grounds the purpose and structure of our existence as being human but also calls the church to live and minister as the "authentic possibility of our existence" because the church comprehends the profound truth that human beings share in the character of God, even in a limited and derivative sense . The church is accountable to the underprivileged and downtrodden. God's society is obligated to stand up for the rights of the underprivileged, the helpless, and those who lack social or fiscal influence. The church provides for the material and social requirements of its members as a sign of a restored sacred and different society, not as if these were the only needs or the only thing that needed to be done. When the church is compassionate, it reflects the character of God and displays its care for spreading his love through both words and actions. It develops into a welcoming society where "the other" or "all" are acknowledged for their agency and power. Gaventa , developed the power cube framework that helps us understand the complexity of power interactions including the different forms of power , different spaces and levels . These places, forms, and levels of authority and power interplay constantly, consequently affecting possibilities and strategies for change. These different dimensions of power can make it difficult to facilitate inclusive dialogue and decision-making. The understanding of these multiple forms of power is equally important as an increase in citizen participation because due to power, certain people are marginalised, while amplifying the voice, recognition, and influence of other people. One important task of leaders is to identify surfacing power dynamics and strategies to shift power in favour of marginalised groups . --- Representation Personal relationships are rooted in social justice. Justice is impossible where there are unequal power ties and where there are no human connections. God created his beings with a strong sense of intimacy, and he actively cultivated this "betweenness" to the point where he willingly died on the cross for them. He left his people with this example of fairness and compassion to live by. Being in partnership and united in affection with one another is what it means to be human. By building a religious community where these disparities do not stand in the way of friendship and affection for one another, the church as an alternative community must voice out against these problems that distort the picture of God in people. When led by this vision, the church will possess doctrinal tools sufficient to help it fight the urge to support race and socioeconomic division . The church becomes a force for healing where human thriving occurs, as a result of its compassionate deeds. The church cannot look on as obvious persecution occurs and stay quiet. Being quiet entails accepting the status quo and taking responsibility for our inaction. Mass devotional gatherings should be held to address this wicked system that undermines humanity's ability to reflect God, but social action should also be prioritised. The alternative community's true religion is manifested in its deeds and actions that show one's affection for God and other individuals. Those who are aware of God must rise and act. Participation should be implemented as both a means of reaching development goals and an end by empowering people to follow their own growth initiatives, projects, and development activities. Therefore, instead of mobilising people behind the predetermined objectives of development agencies, empower people to pursue their own development activities and projects. Development practitioners should adopt participatory behaviour which includes tolerance, mutual respect, openness to differing views, adaptability, and the ability to learn from mistakes to find the synergy between specialist knowledge and the people's knowledge or social capital. Self-critical awareness and reflection are paramount to the process of participation . --- Deductions for a Proposed Praxis for Social Justice As a proposed praxis for Social Justice, we can deduct the following crucial elements of our argument as follows and say that in South Africa, diaconal project goals with a social justice approach should: Be equitable in attempting to rectify unfair disadvantages caused by our history of segregation, discrimination, apartheid, and oppression. Establish concepts of holistic well-being and improvement of quality of life within the specific context. Determine who is happy within the current application of diaconia. When having to choose between the needs of different groups, the needs of the most vulnerable or vulnerable groups should be prioritised. Encourage equal participation by consciously addressing power forms, spaces, places, and levels. Everybody should have the opportunity to influence, decide, and determine fundamental human needs. In addressing these needs, everybody, including marginalised groups, can partake and have access to resources as an element of empowerment. Due to the diversity of needs, a transdisciplinary approach should be adopted to operationalise development. Build relationship by being honest, real, transparent, fair, and compassionate. Remain self-critical and reflective, and re-evaluate goals and the process continuously. Prioritise redistribution. Distribute tasks, information, and resources equally, keeping in mind that individuals have different capabilities. Therefore, vulnerable groups should possibly be skilled, educated, developed, and favoured to enhance the collective goal. In other words, establish equity. Prioritise recognition. Consider cultural and positional differences and adapt development goals accordingly. Recognise resources, recognise power dynamics, recognise talents, recognise social capital, recognise possible dependence, recognise a need for advocacy, recognise a need for voice and identity, and recognise the rights of individuals. Prioritise representation. Be critical of whose voices are being heard. Implement participatory behaviour which includes mutual respect, tolerance, openness to differing views, ability to learn from mistakes and adaptability, and find the synergy between specialist knowledge and people's knowledge. --- Conclusions Throughout our article, a comprehensive understanding can be gained of the characteristics and value orientation of a social justice approach for diaconia. Undoubtedly, when using only one theory for social justice, although it might make some valuable contributions on the one hand, the limitations on the other hand will not do justice to a social justice approach. We have also argued that many theorists made some functional contributions and therefore we are of the opinion that a social justice approach should also include concepts such as empowerment, fundamental human needs, social capital, power relations, and equal participation. Our discussion of social justice has shifted away from a focus on specific initiatives or services, almsgiving, charity, and handouts towards human dignity, equality, and self-realisation, which not only reflects a shift in political philosophy's ethical outlook but also the most recent development in critical social theory. With this identity in mind, the social justice strategy will work to ensure that all individuals and groups are treated with dignity and that all individuals and groups have equitable access to services, provision of services, and growth opportunities. By no means do we put forward that these are the only social justice theories, but we have made a cautious selection of theorists in order to assist us in the purpose of this article, namely, that this approach should assist, first and foremost, the church and also other role players in understanding the new paradigm shift of diaconia as more than just mere paternalistic charities and services towards the establishment of sustainable and empowered communities. As a result of this article, the authors were left with the realisation that additional research and possible publications are needed for further explorations. --- Patents This section is not mandatory but may be added if there are patents resulting from the work reported in this manuscript. --- Data Availability Statement: Not applicable. --- --- 2 The Accra Confession presents a critique of prevailing economic doctrines by drawing upon the conventional Reformed denunciation of idols such as Mammon, consumerism, and financial and speculative markets. These idols are deemed to obstruct God's life-giving sovereignty and contravene God's covenant by marginalising the destitute, the susceptible, and the entirety of Creation from experiencing a complete life. The Accra Confession can be understood as a form of response and resistance to empire. According to the confession, the term 'empire' encompasses the amalgamation of various imperial interests, systems, and networks, including economic, political, cultural, geographic, and military aspects, with the aim of accumulating political power and economic wealth. .

South Africa, although a "young" democracy, has quickly become one of the most economically uneven nations due to its history of segregation and discrimination as contributing factors. South Africans have seen an increase in the number of protests over the past several years because of the frustration that has been caused by unbearable living circumstances, a lack of service delivery, and empty promises made by the government. Poverty, unemployment, and social injustice are seen by the South African government as the most important obstacles that need to be overcome to construct a prosperous nation. Despite the government's commitment to a "better life for all" since 1994, the post-apartheid South African government has predominantly prioritised civil and political rights in its efforts to address social injustices, while the socio-economic needs of the country's impoverished and marginalised populations have remained largely unfulfilled. The degradation of human dignity that results from conditions such as poverty and unemployment is significant. A violation of one's dignity can also occur when one is excluded from efforts to combat issues such as poverty and unemployment, which should be considered. Amidst all of this, the church is criticised for remaining silent and doing little to address the situation. This article proposes social justice as an ideal approach to diaconia and development. Therefore, it seeks to understand and include social justice principles as a means of empowering people to ensure effective development. The objective of long-term poverty reduction cannot be accomplished unless there is an emphasis placed on social justice. This article conducts an in-depth analysis of a variety of social justice theories to rationalise a social justice approach to diaconia.

Introduction After three decades of housing reform, housing assets now represent a significant share of the wealth held by Chinese families, accounting for 37% of the total amount of the family's private assets which are worth on average CHY 930,000 per household . The gender distribution of that wealth, however, is very uneven, as many families register the male household heads as homeowners . According to the Third National Survey on the Social Status of Chinese Women in 2010, only 37.9% of the women own housing property , compared to 67.1% of the men . Among married respondents, 13.2% of the women hold the title in their own name and 28.0% jointly with their spouses, while the shares for married men are 51.7 and 25.6% respectively . In many families whose 1 3 biggest asset is the housing property, this property is registered solely in the husband's name, even though these properties have also been funded by the wife and her parents . Among the unmarried respondents, only 6.9% of the women own their dwelling while 21.8% of the men do . It is thus clear that women own much less housing assets than men. Little literature, however, has tackled the reasons behind this phenomenon. One relevant explanation is that the female partners generally have a lower income than the males and therefore contribute less to the financing of the family home. The average annual income of females is merely 67.3% of the income of males in urban areas and 56.0% in rural areas . An often overlooked reason for women to own less housing property lies in the fact that females receive less intergenerational transfers than males . Considering the high price of housing in China, one can hardly afford home ownership without pooling resources derived from family members. This is especially true for young adults, who do not have built up much savings. While some parents make great sacrifices to help a son buy a home, they tend to decline a daughter's request, even if they have the means to help out . The improvement of gender equality in nutrition, health conditions and educational opportunities in China is documented in the literature . Yet, gender equality in wealth and asset owning is lagging behind. In this domain, the Chinese market reform and the trend towards individualism of property ownership seem to work in the direction of a widening gender gap. At the same time, women's economic security and well-being have become a crucial issue in the rapidly aging Chinese society where the policies hope to boost fertility. Thus, this paper contributes in two ways. First, it reveals the gender inequality in opportunities to accumulate housing assets and the role of intergenerational transfers in this phenomenon. Second, it systematically analyzes the connections between welfare state, family reciprocity, home ownership and gender in the context of China, thereby providing a framework for future comparative research. In another contribution, we have elaborated on the negotiation processes that underlie intergenerational transfers for the purpose of home ownership . In this paper, we will investigate how the gender of an adult-child affects these negotiation processes. Utilizing 31 in-depth interviews from Chongqing, this paper answers two research questions: How and why does the gender of the recipient affect the negotiation of intergenerational transfer on home ownership? and, against this backdrop, What are young women's possibilities for accumulating housing assets? The answers to these questions will be framed within the broader system of social coordination outlined above. The next section presents the conceptual framework of "social coordination" in more detail. Subsequently, we describe the contextual background of China through the lens of this framework. Then, a summary of the research methodology and data collection process is given. The empirical analysis consists of two parts. The first elucidates how intergenerational transfers on home ownership are differentially directed to male and female adult children; the second describes how young women cope with this and elaborates on their possibilities to accumulate housing assets. The final section summarizes the research findings and discusses their wider implications. --- Literature review and conceptual framework --- Social coordination of welfare state, home ownership, family reciprocity and gender division --- The system of social coordination Existing research has noticed the substitution effects between welfare state and home ownership, and between welfare state and family reciprocity. When social protection is not available to the public and the generosity of the welfare state is limited, individual households are motivated to accumulate private assets to offset income uncertainty over the life course . A common way for families to accumulate assets is home ownership . Homeowners can reduce the cost of living and ensure a safety net to offset financial risks . There is also a trade-off between state and family as welfare providers. Without or with limited public welfare, individuals have to rely on the mutual support of the families, particularly intergenerational reciprocity, to provide care and offset risks in the long term . In developing and underdeveloped countries where the welfare state is not effectively established, extended families in which different generations can help each other are common. And vice versa, in developed countries where intergenerational reciprocity is encouraged in culture, such as in East Asian countries, the development of the welfare state is confined . Family reciprocity also works within one generation, in the form of the male breadwinning model; the incomeless wives use their free labor at home to reciprocate their husbands' responsibility in providing cash income for subsistence . In a little developed welfare state with a high percentage of home ownership, family reciprocity in intergenerational transfers of housing property is important. In a homeowner society, access to alternative tenures is limited and living in an owner-occupied home becomes a social norm . A high demand for home ownership coupled with insufficient access to the rental sector may drive up the price of owner-occupancy properties. As a consequence, home ownership is often unaffordable for young households unless they receive support from parents and/or other family members . Parents are usually inclined to help out, as home ownership is a good investment for the family and their help could evoke reciprocity from their children, which is the major source of support in old age when welfare state provisions are limited ). We call the interconnectedness between welfare state, home ownership and intergenerational reciprocity discussed above "social coordination", as it illustrates how individuals, families, and the state are connected in a society . --- Home ownership, family reciprocity and welfare state in China In another publication , we document how reciprocity works in smoothing the exchange between parental help in accessing home ownership and the children's support in old age care. The expectation of reciprocity plays a key role in deciding whether an intergenerational transfer takes place. Basically, the parents only make the transfer when they view the beneficiaries as trustworthy providers of old age care. Some adult children, under the purpose of maintaining their autonomy in deciding an acceptable level of filial duty, refuse or avoid asking for support of their parents. The reciprocity expected by the parents can be financial, instrumental, or emotional, depending on the needs of the parents and the availability of the children in due time. This exchange is not to be explicitly discussed during the process of negotiation, but it is well understood and perceived justified by the adult children. We also observed an influence of the welfare state on the motivation of intergenerational transfers. In the current Chinese welfare system, rural residents receive far less state welfare than urban residents. This motivates them to invest more in intergenerational reciprocity, while the urbanites can be more altruistic in the transfer. Households with a rural migration background are more willing and more likely to feel responsible for supporting their children in getting access to home ownership than their urban peers, even though they have fewer resources to do so. --- The role of gender In this paper, our main concern is to add another dimension in the triad of social coordination-gender. Gender divisions are important in the understanding of how individuals, families and the state are organized in a particular society. In most of the preindustrial societies and to a lesser extent but far from extinction in the industrialized societies, production and property ownership are organized along lines of gender. The men work outside the family as the "bread-winner" and represent the household in public. They are recognized by the community and the authorities as the "head of the household" and the owners of family properties. Women, on the contrary, provide services and care within the household without any monetary compensation. They are viewed as dependents of their husbands and fathers, which implies that they cannot hold properties . The gender 1 3 differences did not disappear when welfare states started to develop and social protection became a civil right. After all, the organization of social protection is often gendered as well. Many modern welfare states are still based on the male breadwinner model in which the male workers receive a "family wage" to support their wives staying at home and doing unpaid house and care works . After decades of feminist movement and progress in social policies, gender gaps in education and income have in different extents diminished in many developed and developing countries. Yet, the gender gaps in the distribution of property and assetholding remain persistently large . Direct or indirect discriminations affect women in the distribution of proprietary resources in both private and public spheres, such as in inheritance of properties , in registering the ownership of housing, in taking mortgage loans , in the distribution of land and in the allocation of social housing . Female-headed households in particular experience significant disadvantage in terms of accessing and sustaining appropriate housing . In next section, we will apply the perspective of social coordination and examine how welfare provision, family relations and housing are linked in the context of traditional and contemporary China. --- Social coordination in China: from past to present --- Social coordination in traditional Chinese society In traditional Chinese society, the provision of housing was always associated with elderly care and generally arranged patrilineally . In a patrilineal society, marriage is normally patrilocal; residing matrilocally is deemed socially undesirable. Patrilocal means that the groom's parents prepare a space so the new couple can move in with them and become co-resident. After marriage, the bride becomes a member of the groom's family and will care for her husband's parents rather than for her natal parents. The children of this couple would also be named according to their father's genealogy. In this way, a Chinese family is reproduced patrilineally. Housing, both as living space and property, is an important link in this chain of reproduction. A home is both a practical place and a symbolic space . In this way, providing housing, either financially or in-kind, justifies the providers' rights to care and enables them to receive it . Consequently, in traditional Chinese society, there is a preference for sons. Only sons are considered permanent members of the family and the source of care. As a result of this, girls receive much less from the family in terms of resources and investment . They receive less nutrition than boys and they carry out duties within the household from a very young age. They are relatively deprived in terms of formal education and human capital accumulation. --- Social coordination in contemporary China The Feminist movement in the twentieth century campaigned for gender equality and women's access to civil rights such as freedom of marriage and divorce, right to education and formal occupation, and right to acquire and maintain properties. The Communist regime particularly promoted women's participation in the labor force and gender equality in allocating job opportunities, as means of mass mobilization and means to facilitate industrialization . --- Chinese welfare state From 1949 and onwards, a nationwide welfare system was gradually developed. It started in a very preliminary form, covering only state employees, and gradually expanded into a somewhat more comprehensive system. The current Chinese welfare system has eligibility criteria based on formal employment and benefits based on contribution, which means that women can only gain access to social benefits if they are paid workers and contribute to the social security fund. As a result of lower female participation in the labor force and lower pay scales, only 54.1% of the elderly females in the cities have pension, compared to 79.3% for their male counterparts. In the countryside, the gap is even wider: 38.8% for females and 59.1% for males . Even though gender equality is still on the official political agenda, state institutions in many domains are suppressing women's rights toward land and housing, under the assumption that they will get it from their husbands . Women have been more vulnerable than men to forced acquisition and have had to protect their land rights, though with far less success than men. In 2010, 21.0% of the rural women were landless, 9.1% higher than the rate for rural men . Furthermore, current Chinese laws do not provide mechanisms to distinguish women's property rights within the household. Therefore, if the marital status of a woman changes, her rights to family property such as land and housing can be easily infringed . --- One-child policy and family reciprocity From 1982 and onwards, China launched the so-called "one child policy", stipulating that in principle each couple should only have one child. This policy is applied strictly in urban areas but somewhat more loosely in rural areas . As a result of the policy, the fertility rate dropped from 2.7 in 1986 to 1.5 in 1997 and has since remained stable . A line of research suggests that the one-child policy reduced the number of competitors for a family's resources and improved gender equality to some extent. Under this policy, single-child girls and girls with only female siblings receive more education than girls with male siblings . Many families, even from rural background, started to encourage their daughters to pursuit a career and provide help such as child care . However, the improved gender equality is not yet visible statistically in the allocation of family property and assets. Even though the inheritance rights of daughters are written in law, inheritance allocation only to sons still dominates in rural areas . Why women own less housing assets in China? The role of… 1 3 A survey from the 1990s showed that only 40% of urban residents and 14% of rural residents agree with shared inheritance among daughters and sons . Post-reform policies pay more attention to the protection of individual property rights and interests. Different from family policies in the socialist era which emphasized protection of women, current policies highlight the financial contribution and rights toward the family assets of the breadwinner and loosen the rights of the female homemakers. As divorce rates and disputes over marital property rise, a new judicial interpretation of the Marriage Law was issued in 2011. This new interpretation stipulates that the housing property paid by one spouse before the wedding belongs to the payer In recent years, with children that are born under the one-child policy reaching marriage age, new dynamics were introduced in family relations and power structures. The existence of families with only daughters challenged the patrilineal family reproduction model, as parents in these families also need care from the daughters and sons-in-law; the parents of the bride and groom have to compete for priority in their children's future caregiving. Considering the direct linkage between the surname of the grandchild, housing provision and rights to care, some parents of the brides insist to finance the new couple's home in order the gain the right of surnaming and future care . If the parents contribute significant amounts to their children's home ownership, they are not only more likely to arrange a desirable location at which they would eventually receive care but are also holding the moral high ground, either to claim their children's reciprocal care or to use part of the equity stored in their children's home to pay for institutional care and health treatment . Thus, a gendered relation of housing intergenerational transfer and age support can no longer be automatically assumed. Instead, case-by-case negotiations become the norm. In such negotiations the financial ability of the bride or groom's parents, the affection between adult children and parents, and the geography of their residence, play a crucial role. --- Research design 1 Chongqing has been the international trade and administrative center of Southwest China since the 19th century and was the capital city from 1937 to 1944. The core area, Yuzhong District, has been occupied by families established there for generations. They were employed in the administrative, trade, and service sectors and lived in crowed privately owned homes. During the 1960s, Chongqing experienced rapid state-led industrial development and has since established itself as one of the centers of heavy manufacturing in Western China, with more recent settlers working in state-owned factories. During the economic reform of the 1980s and 90s, many immigrant workers came from nearby rural areas and found informal employment in the rapidly growing private sector. Being one of the four cities controlled directly by the central state and the only one in inland China since 1997, Chongqing's vigorous development has attracted many migrants with high educational qualifications from both rural and urban areas. In our study, we approached all three groups-the locals, urban migrants, and rural 1 3 migrants-as the public welfare systems they have entered were different. The state workers enjoy the best public welfare and receive support for education, career development, and housing from the state. The established residents working in the private sector receive less from the state but can fall back on the family resources accumulated over generations. Finally, new migrants that have arrived after the economic reform tend to receive less state support and their earning capacity varies according to their educational qualifications. The fieldwork was conducted in the metropolitan area, consisting of nine districts with an approximate area of 500 km2 and a population of eight million . The data was collected in November and December of 2015 and 31 participants were interviewed with the help of a semi-structured interview guide. The interviews were started with an information table collecting a range of basic information: the demographic and socio-economic status of each member of the extended family; the housing history from birth, including the time period, location, dwelling type, dwelling size, affordability, tenure situation, and living arrangement for each period of occupation; the payment structure of the first and current dwelling, i.e. who pays for what percentage of the total value. The semi-structured interviews also addressed the following two topics: the process of home purchase, particularly who initiated the purchase and how the payment structure was negotiated and settled; the perception of and attitude towards intergenerational transfers, both within the own family setting and in general terms. The semi-structured interviews lasted from 45 to 75 min, depending on the complexity of the story. The language used in the interviews was Mandarin or the local dialect. Immediately after the completion of the interview, the interviewer wrote up a short summary of the participants' opinions and relevant non-verbal impressions. All interviews, except two 2 , were recorded and subsequently coded using Atlas.ti 7.0. The participants were given numbers so that they can remain anonymous, and quotations from their responses have been translated from Chinese into English. The participants were selected by a purposive sampling method under the principle of maximum diversity. First, we targeted and categorized three groups of young people: locals, urban migrants , and rural migrants . Second, within each group we recruited a sample with maximum diversity in terms of age, gender, occupation, education, income level, life course, housing and living arrangements and intergenerational transfer experience . In a few cases, both partners of the couple were present during the interview and they were registered as one case. Parental participants were recruited along the same lines. We recruited parents with a range of experiences with regard to equity transfers . A minority of the parental participants were parents of young adult participants that were also recruited. In such situations, parents and young adults were interviewed separately from each other. More details on the participating parents can be found in Appendix 2). Participants were approached through snowballing method, starting with personal contacts. This approach was taken because the topic of this research is both private and sensitive and recruiting from a pool of acquaintances helps build trust. We kept on recruiting research participants in these three groups with an eye to variety in other respects until information saturation was reached. At that point, information from participants started repeating itself, and no new themes pertinent to our research questions came to the fore, even when new participants with a different background were recruited. In total, 22 young adults aged from 24 to 41 and nine parents aged from 49 to 60 were interviewed. Eleven of the 22 young participants had received an intergenerational transfer from their parents. Of the nine parents that were interviewed, six had provided an intergenerational transfer to their children . --- The gendered intergenerational transfer of housing assets The patrilineal tradition leads to different strategies for saving and housing planning with salient differences between families with male or female children. Families with male children would plan a home for the sons well in advance of marriage and start saving money for that purpose. Families with female children, on the other hand, rarely make any proactive financial arrangements. However, on top of gender family size matters as well, as the next two Sections will show. --- In multi-child families If a family has both male and female children, which is the case for many rural migrants, the parents only prepare for their male children's home. In our home town, it is all like this. Parents would prepare a home for their sons. Houses are cheap in my home town, so my parents just bought a home for my two brothers. It is more expensive in Chongqing, so my mom can only help me with mortgage down payment. … No help to daughters. In my home town, normally parents wouldn't support daughters as they will marry out. 1 3 However, for young migrants who plan to buy a home and settle down in the city, resources received solely from the man's family are often not enough. The young couple would ask for help from the wife's family too. In such circumstances, resources from the husband's parents are often a gift, while help from the wife's family is implicitly an interest-free loan. After we decided to buy a home, we asked our parents with how much money they could help us. My parents gave me all their savings, so after the home was ready they move in with us and left their rural home. But in my family, this is a loan. I borrowed from my parents, my brother, and my sister. We repay them later. A gift from the male's side and a loan from the female's side form a combination that also applies to Case 21. As the research participants point out, this combination is a direct result of the patrilineal tradition and the linkage between parents' housing duties and adult children's elder-care responsibility. I think this has something to do with the traditional household structure. Because my wife is daughter and her parents, from deep of their heart, believe that they should rely on their son for age support. It also has something to do with the culture. For home purchase, traditionally it is the responsibility of the male's family. The female's family would not be taking care of this stuff. Even nowadays in many single-child families. --- In single-child families The female participant in Case 21 is correct in suggesting that even in those single-child families from an urban background, a gender discrepancy still exists. Parents of a male child start planning for their son's home a long time in advance. If their financial situation allows it, these young men become homeowners when they are still in college or immediately after they start their first job. Often, it is the parents who come up with the down payment and the young men pay the monthly installments on the mortgage. After marriage, the wives of these home-owning young men would move in with them. My parents paid the down payment. I paid the monthly installment. Our main purpose is to prepare a home for future marriage. Another motivation is investment. After I graduated from college and start to work in this hospital, my parents offered me all their savings and asked me to buy a home. Families with only daughter tend not to plan for their child's future home, as they consider it the responsibility of her future husband's family, but some parents register their daughter's name as the proprietor of their own home. Unlike similar behaviors in families with a male child, these homes are not devoted to the daughter's use for independent living or marriage. It is more like a strategy to secure support from the daughter, by assuring the property as bequest in the future. I think my daughter's and her husband's home is her husband's family's responsibility. We can contribute a share, but her husband's family should contribute more. My parents won't buy a home for me. They think, after marriage, it is the husband's responsibility…. But they registered their home under my name. That is to avoid transfer costs in the future, but it is still their home. I never feel that is my home…. After my divorce, my father did not allow me to use it because he did not want me to divorce. In Chinese culture, the male children are primarily responsible for providing old age care to their parents. It is in exchange for this responsibility that they receive intergenerational transfers. However, in situations where male age supporters are not available, such as in multi-children families with no sons or in single-child families with only a female, it is possible for female children to receive such transfers. This is most clearly illustrated by Case P8's explanation on why she insists on helping both her daughters in acquiring home ownership. I have to prepare some money for my old age. And we should also help my younger daughter since we had helped our older daughter. … We don't have that fortune to have a boy, the only thing we can do is to help our daughters. Nowadays the duty of supporting aging parents is the same for sons and daughters. --- Young women's opportunities to accumulate housing assets Even though parents with female child rarely take the initiative for providing intergenerational transfers, there is room for young women to negotiate and maneuver. This section describes three different possibilities that young women have to accumulate housing assets. Based on the availability of parental support and their own earning power, some young women secure housing assets independently before marriage while others secure assets together with their partners after marriage. Finally, in the absence of parental support and own earnings, some women cannot accumulate any assets and therefore become financially dependent on their partners. Below, each of these three situations are described in more detail. --- Seek help from parents Some of the young women in our research successfully established independent home ownership while they were unmarried. This means that no matter what happens to their marriage in the future, whether they remain unmarried or get divorced, their residence and financial safety net is stable. They can hardly establish such a position without parental transfers, however. In other words, an independent housing asset for women usually means independent from husband and marriage but in fact dependent on parents. This is nevertheless a privileged position for young women and requires the concurrence of several circumstances. In our research, the cases 03, 13, and 14 belong to this group. They all have an urban background and are the only child in their families. They are the initiators of the intergenerational transfer that they received from their parents, with which they have a close relationship that is characterized by a high level of trust. 1 3 I know that housing prices in China, also in Chongqing, will rise. And my working place is far away from my parents' home. It took me one hour one way, very inefficient. So I proposed to my parents that I want to buy a home. And I convinced them. After I decided to settle down in Chongqing, I immediately started home viewing and I asked my parents to help me. … I think a woman should have her own home, although people said the man will provide you with accommodation after marriage. But I would feel unsecure if I would not have my own home. My relationship with my husband is good, but I still want my own home. One important reason why these women received support from their parents lies in their mothers' personal experience in the patriarchal families and their concern for their daughters' financial independence in marriage. Our idea as parents is to prevent the man from looking down upon our daughter, from putting financial pressure upon our daughter. My daughter shouldn't be financially dependent on her husband. --- Co-owning with husbands If owning a home before marriage is not feasible-and that is very often the case-buying a home together with their husband and becoming a co-owner is another possibility for married women to accumulate some housing assets. In order to claim a share in home ownership, either the wife or her parents would need to contribute a share of the purchase price. When young women want to use their own income , they would probably only have the chance to do so if the couple were to decide to buy a second home and if they had sufficient income to do so. That is because many young men already own a home before marriage. And these homes, in most cases, are fully paid for by the husband's parents or jointly by the husband and his parents. Thus, the couple's motivation to buy a second home, other than for holidays, upgrading or investment, would be to strike a balance between the financial interests and powers of the husband and the wife . We purchased another home earlier this year. The home we currently live in is, after all, purchased by my husband and his parents, but the new home is ours [my husband's and mine]. Making a financial contribution is not the only way to justify a woman's claim to the marriage home. As women play a major role in unpaid housework and care, in the view of many men and women such services justify women's rights to family property. Although my income is much lower than my husband's, I don't feel inferior to him. He makes money outside, but all the domestic work like child care depends on me. He offers money and I offer labor. I think if the woman wants to have a share in the marriage home, she should share the responsibility. It does not mean that this woman must work, but she should fulfill her duties at home, for example taking care of the child and the elders. In some cases, women get 'compensated' for their domestic services and chores by getting access to the assets that are accumulated in the house in which they live. Consider, for example, the first marriage of Case 16 and Case 02's current husband. Although the husbands brought in the full amount of money that was needed to purchase that marriage home, they registered their first wife as the only owner. And thus, after the dissolution of their first marriage, the property went to their ex-wife. Case 16 explained his rationale like this: Women are more vulnerable. Let's say if our marriage didn't work out, as a man, even if I am 50 years old, I still have chances. But for a woman, where does her sense of safeness comes from? Only from the man. Besides her man, what else she can count on? However, justifying home ownership through a woman's care and services is not standard institutionalized behavior. Only if the husband voluntarily registered the wife as the home owner at the moment of purchase and does not retract this registration in a divorce court afterwards , the woman has a right to the property concerned. Thus, a woman's ownership or co-ownership through domestic service is at the mercy of the man. It is thus important for women who do not have parental support in asset transfer, and particularly so for those who do not get good pay in the labor market either, to select a financially capable and virtuous husband. I won't consider a man who doesn't have a high income. But it is not only about income, it is also about his moral quality. I am lucky. I have dated my current husband in high school. He raises no suspicions in me. He has a good income and he is willing to support me financially. When the kids approached the age of school, he said we should buy a home and let our child go to a good school. So he bought a home and registered me as the owner. --- Dependent wives Women who did not receive parental help and did not make a direct financial contribution to the home generally do not accumulate housing assets. Instead they depend on their husband's housing assets. If the marriage is stable, there is no problem. But if anything goes wrong and the marriage breaks up, these women may end up without any monetary compensation. Thus, non-owning wives are more vulnerable in the marriage than owning wives. Fearing homelessness, some women are forced to stay with a violent partner or in an unhappy marriage . In my first marriage, my ex-husband's mom purchased a home for him. So after we married, we moved into that dwelling. Then after I divorced him, I moved out. After my older sister got divorced, she is in hardship. So I invited her to live in our home and we support her spending. I helped her to look for jobs and her daughter coming to study in Chongqing. Now she has found a stable job and she has moved out. 1 3 Some women miss the chance to make a financial contribution to the marriage homefor example, if this home has already been purchased outright by the man's parents. For these women, it is very hard to reverse the situation, even if they have a paid job. Purchasing another home is the only option open to this group. This is exactly the situation Case 02 faced in her first marriage. Since the husband already owned a home and had no immediate incentive to buy another one, the wife needs to have substantial earning power to initiate such a purchase and/or at the same time be able to convince her husband or parents to contribute too. Because women are mostly responsible for the housework, their income is usually spent on daily consumption rather than saved up to buy another home. The parents play an important role in helping young women with the accumulation of housing assets. Not only can they give financial assistance, they can also offer child care, thereby enabling the young women to continue a full-time career. Because there is almost no public child care in China and private child care is expensive and untrustworthy, many families rely on grandparents to care for young children . If, for reasons like health or migration, the grandparents are not available, the young mother would have to stay home to take care of the child. In this situation, the woman would make no financial contribution to the household, so it may be harder for her to claim a share in the family assets, especially when the husband is struggling to shoulder the housing costs alone. We asked if my parents-in-law would like to move in with us and help us with child care. But they don't want to. They don't want us to be too dependent on them. So my wife stayed at home for child care….When we were buying our marriage home, it was so hard. I asked help from my parents-in-law but they didn't help us. They are not rich either. I have no choice. My name is on the property certificate, so I have to work hard and repay the mortgage debt by myself…. So now I am the owner of our home. --- Conclusion The literature shows that parental background and the availability of intergenerational transfers largely determine the chances that young adults will be able to attain home ownership. This paper has elucidated the mechanisms underlying these factors by exploring the relationship between intergenerational transfers and gender. We chose to position our empirical study in China, a country with severe housing affordability problems and a persistent patrilineal family tradition. The empirical study for this paper was carried out in Chongqing, Southwest China. Although we don't claim that Chongqing is representative for China as a whole, we do think that the mechanisms that are described in our paper have a broader relevance for Chinese society. Utilizing 31 in-depth interviews from the city of Chongqing, we investigated two questions: How and why does the gender of the recipient affect the negotiation of housing-asset intergenerational transfer? and, against this backdrop, What are young women's possibilities to accumulate housing assets? Our study in Chongqing has elucidated the gendered practice of intergenerational transfers for home ownership in China. In multi-child families, parents prepare for and transfer housing assets to sons prior to or at the moment of marriage, whereas they would at best provide interest-free loans to daughters upon request. In single-child families, parents would not prepare a housing-asset transfer for their daughters, as they expect their daughter's future husband and his family to do so. Under these circumstances, ownership of housing assets before marriage is much less common among women than among men. And not only do women bring fewer assets into the marriage, they also have a disadvantaged position in the labor market. Therefore, the family home is often in the possession of the man and the accumulation of housing assets during the marriage is difficult for women. Consequently, women face the risk of losing access to their family home and being without assets if their marriage status changes. Against this background, young women in Chongqing embark on three different scenarios for housing asset accumulation, based on their parental resources and their own earning power. When parental help is available, some young women successfully establish independent housing assets while they are still single. Their control over these assets is not subject to changes in their marriage status. Furthermore, without utilizing parental resources, women can still establish co-ownership with their husband by sharing in the mortgage payments. In many cases, however, a woman can only become a co-owner if the couple buys a second home, as the first one is often purchased by the husband and his parents. Finally, some women, do not possess any housing assets. For them, not only is financial help from parents out of reach, but their own earning power is constrained by the fact that they have no help with child care and household chores. The social status of Chinese women has improved substantially in the last half a century due to the economic independence they get from labor market participation. At the same time, their lagging behind in holding housing assets becomes a new source of inequality. Our research shows that women's disadvantage in holding housing assets is not only caused by their lower earning power in the labor market but also, and probably more so, by gender discrimination in the provision of intergenerational transfers. This discrimination is rooted in China's traditional patriarchal power relationships. These relationships were mitigated by the socialist movement between the fifties and the seventies but are coming back now that private ownership of housing has become the norm. In the post-reform Chinese social coordination system, there is an increased emphasis on family reciprocity and home ownership, which reinforces the gender gap in housing asset-owning between men and women. In this paper, we introduce the conceptual framework of social coordination and we use this framework to analyze how Chinese men and women have differentiated opportunities to access home ownership and to accumulate housing assets. This framework uses a holistic approach to analyze the mutual influences between welfare state, family reciprocity, home ownership and gender. Future analyses based on this framework may help to understand how social policies and housing policies influence gender relations and fertility rates, or to understand how gender divisions influence the sustainability of the housing system and welfare state. The social coordination framework can also be helpful in comparative studies that aim to explain the different institutional choices and outcomes of different countries. Personal or couple annual income, Chinese Yuan, 1 = below 50,000, 2 = 50,000-100,000, 3 = 100,000-500,000, 4 = 500,000-1,000,000, 5 = above 1,000,000, n no answer d Personal or couple total assets, Chinese Yuan, 1 = below 50,000, 2 = 50,000-100,000, 3 = 100,000-500,000, 4 = 500,000-1,000,000, 5 = 1,000,000-5,000,000, 6 --- Appendix 1 See Table 3. Personal or couple annual income, Chinese Yuan, 1 = below 50,000, 2 = 50,000-100,000, 3 = 100,000-500,000, 4 = 500,000-1,000,000, 5 = above 1,000,000, n no answer c Personal or couple total assets, Chinese Yuan, 1 = below 50,000, 2 = 50,000-100,000, 3 = 100,000-500,000, 4 = 500,000-1,000,000, 5 = 1,000,000-5,000,000, 6 = above 5,000,000, n See Table 4.

After three decades of housing reform in China, housing assets constitute a sizable share of family wealth but are distributed unevenly, as registered homeowners are predominantly male. This is partly because males generally have higher incomes than females and can therefore contribute more to the financing, but also because males receive more intergenerational transfers. On the basis of 31 in-depth interviews from Chongqing, this article seeks to answer two questions: (1) How and why does the gender of the recipient affect the negotiation of intergenerational transfers? and (2) What are young women's possibilities to accumulate housing assets? The research findings show that young women either ask their parents for help to secure housing assets before marriage or they attempt to co-own a home with their husbands after marriage. Women who do not succeed in either of these strategies do not accumulate housing assets and thereby risk their rights to the home if their marriage is dissolved.

Background It is critical to consider the fact that most prison inmates are parents. The mass incarceration of parents in the United States is a rapidly growing problem with issues of race and ethnic disparities and poor outcomes for children of incarcerated parents . Mass incarceration impacts child mortality and population health . Women with family members who were currently incarcerated had increased odds of being obese, having had a heart attack or stroke, and being in fair or poor health . Incarceration of a woman or her partner in the year before birth was shown to be associated with higher odds of maternal hardship and poorer perinatal health behaviors . Many female prison inmates have had incarcerated adult family members during childhood as well as high rates of neurological impairment in adulthood . Hundreds of millions of people worldwide are affected by neurological disorders, and the extension of life expectancy with ageing populations in both developed and developing countries are likely to increase the prevalence . The World Health Organization has determined that dementia is a public health priority. Dementia is a syndrome that affects memory, thinking, and behavior. The number of people living with dementia worldwide is currently estimated at 35.6 million and is projected to double by 2030 and more than triple by 2050 . Increased susceptibility for dementia and cognitive decline that is reported later in life after traumatic brain injury may result from brain tissue loss that increases throughout the chronic post-injury phase, suggesting that TBI accelerates the rate of brain aging and atrophy . TBI, most often resulting from accidents, violence, and falls, is the leading cause of death and disability in children and young adults world-wide resulting in loss of many years of productive life, disability, and neurobehavioral problems . Health promotion is particularly important for neurological disorders by identifying those at risk and providing resources for rehabilitation and prevention of the projected escalation. In order to break intergenerational cycles of physical and emotional trauma and criminal behavior , it is imperative to continue to better understand factors contributing to it. Protective factors against violence perpetration such as measures related to parental expectations and connectedness with parents and other adults are difficult to achieve when adult family members are incarcerated. Family disorganization, dissolution and violence, which are often the case when an adult family member is incarcerated, can be risk factors for childhood abuse. There are numerous effects of adverse childhood experiences on physical health including neurobiological findings such as memory impairment and long term health risks . Adverse childhood experiences significantly increased risk of many health-harming behaviors for physical inactivity, obesity, attempted suicide, and neurological decline . Having an incarcerated parent during childhood has been shown to be associated with numerous poor health outcomes in young adulthood including depression, posttraumatic stress disorder, anxiety, cholesterol, asthma, migraines, HIV/AIDS, and fair/poor health . Because little is understood about long-term neurobehavioral outcomes of children with incarcerated adult family members, the aim of the researchers was to elucidate the impact of having incarcerated adult family members during childhood on neuro-behavioral health throughout the lifespan of females. --- Methods --- Design and Sample Because of the high rate of incarcerated adult family members in the lives of female prison inmates, and high rates of neurological impairment in this population, a secondary analysis was conducted of data from private interviews and examinations to understand how having incarcerated adult family members during childhood could influence neurological health throughout the lifespan. A modified case-control design was used to compare female prison inmates who had incarcerated adult family members during childhood to female prison inmates who did not have incarcerated adult family members during childhood. Adult female prison inmates were randomly recruited from both minimum and maximum security sections of a prison in a Mid-Atlantic state in the United States. All data were collected during private interviews and examinations conducted by the first author. Detailed methods have been reported . The sample size determined based on the parent studies was adequate to provide power to find a moderate effect with N=135 female prisoners and alpha =.05. Eightyone percent of eligible inmates volunteered to be in this study. The study was approved by the institutional review boards of the principal investigator's institutions and all participants signed written informed consents. Procedures were conducted in accordance with federal regulations for the conduct of research with prisoners . --- Measures Incarcerated adult family members during childhood were self-reported. Muenzenmaier's scale was slightly revised to assess frequency and severity of sexual and physical abuse before age 18. It has reported validity and reliability in tests of women of similar age, ethnic background, and education including mentally ill women . Higher scores indicate greater frequency and severity of abuse. Other data collection included abuse that resulted in health care treatment. They were also asked if any items on the abuse scale occurred since age 18 and when it occurred last. Self-reports were verified by evidence of physical injury and records when available. General health and specifically neurological histories and physical examinations were evaluated by a certified neuro-rehabilitation clinical nurse specialist in accordance with standards that were validated by two neurologists and a neuropsychologist. Documentation and other examination evidence to support histories provided by each inmate was investigated, such as neurological deficits and cranial-facial scars or palpable areas of skull damage consistent with self-reports of traumatic injuries and other neurological histories. --- Analysis Statistical methods included frequencies, t-tests and graphical checks. Childhood abuse scores and number of neurological histories and neurological examination abnormalities were dichotomized by the mean to indicate high scores compared to low scores. Logistic regression statistical analyses were then used to compare adult female prison inmates who had incarcerated adult family members during childhood to those who did not for each of the main variables. --- Results Of 135 adult female prison inmates, 99 had at least one adult member of their extended family incarcerated when they were a child. Hispanic and African American inmates had disproportionately high rates of incarcerated adult family members during childhood . There were no significant differences in age, years of education, or violent crimes committed by participants who had incarcerated adult family members during childhood and those who did not. Bivariate logistic regression revealed that having at least one incarcerated adult family member during childhood was related to having been a victim of childhood sexual abuse , greater total childhood physical and sexual abuse scores , greater number of neurological history reports per person prior to the current crime such as traumatic brain injuries , and greater number of neurological examination abnormalities per person in adulthood , compared to those without incarcerated adult family members . Neurological histories and/or neurological examination abnormalities were evident in 95% of this random sample of female inmates. Other than traumatic brain injuries, neurological histories included exposure to lead and/or other toxin, stroke, seizures, central nervous system infection, CNS tumor, having been the product of a complicated pregnancy and delivery, migraine, survived cardio-pulmonary resuscitation , was struck by lightning, other loss of consciousness such as due to choking, myasthenia gravis, and/or had undergone a neurosurgical procedure. Each neurological history report was added for a total number of neurological history reports per person. For example, someone with 3 TBIs was coded as 3. Recurrent TBI was particularly prevalent with most occurring during high risk behaviors such as while they were under the influence of alcohol or other substances. Neurological examinations corroborated with neurological histories with the most frequently occurring deficits including cranial nerve deficits, extremity weakness, gait abnormalities, rapidly alternating movement deficits, less than 3 word recall memory deficits, cranial facial scars, and palpable evidence of skull injury. Females with incarcerated adult family members had a significantly earlier age of their first criminal conviction. Though there were a greater number of suicide attempts per person in the group with incarcerated adult family members, the difference was not statistically significant. Obesity was not significantly higher for those with incarcerated adult family members during childhood. Inmates described a series of events, often childhood abuse, contributing to their lack of regard for themselves and others often resulting in substance abuse and high risk behaviors for accidents, altercations, infectious disease transmission, and ongoing neurological decline. History of having been a victim of greater frequency and severity of childhood abuse placed one at greater risk of abuse in adulthood . Abuse in adulthood was significantly related to a greater number of neurological histories and neurological examination abnormalities . Abuse in adulthood was related to greater risk of suicide attempts . --- Discussion More than half of adult female prison inmates had at least one adult member of their extended family incarcerated when they were a child. Adult female prison inmates with at least one incarcerated adult family member during childhood were 2 times more likely to have been a victim of childhood sexual abuse, 3.2 times more likely to have higher total childhood physical and sexual abuse scores, 2.7 times more likely to have more neurological history reports prior to the current crime such as traumatic brain injuries, and 2.6 times more likely to have more neurological examination abnormalities in adulthood compared to those without incarcerated adult family members. Having been a victim of greater frequency and severity of childhood abuse placed female prison inmates at 2.6 times greater risk of being abused in adulthood. Females abused in adulthood were 1.3 times more likely to have neurological histories and almost 1.5 times more likely to have neurological examination abnormalities. Neurological impairment is related to self-destructive high risk behaviors for further neurological decline such as for HIV transmission and altercations that can result in further neurological decline in this population of female prison inmates . Abuse in adulthood results in 3 times greater risk of suicide attempts. History of childhood sexual abuse and suicide attempts places adult female inmates at greater risk for obesity . Furthermore, recent abuse in adulthood and TBIs are related to violent criminal behavior in female prison inmates . In addition to the obvious neurological impairment associated with TBI, there are multiple mechanisms through which childhood sexual abuse can contribute to adverse brain development and behavioral dysfunction . --- Strengths and Limitations Because this was a secondary analysis and not the original research question, researcher bias was not a risk. Cause and effect cannot be determined by this design because it was a cross sectional study. We cannot determine in all cases if neurological impairment occurred before or after childhood abuse because children at particular risk are those with special needs that may increase caregiver burden. However the correct temporal sequence occurred with adult family members incarcerated during childhood and childhood abuse occurring prior to the current incarceration and neurological examinations. Most neurological histories also occurred later in life and continued to result in a spiral downward to greater neurological decline related to increased high risk behaviors, such as those leading to accidents or altercations resulting in recurrent TBIs. Furthermore, the number of neurological history reports describes mainly the frequency of recurrent TBIs per person, but not the severity or anatomical location of the injuries. --- Direction for Future Intervention and Research Sadly, in the decades since the closure of long-term mental health facilities throughout the United States and decrease in long-term inpatient neuro-rehabilitation, incarceration rates escalated with the vast majority of prisoners suffering from mental health problems that include both psychiatric as well as neurological conditions. Mental health facilities had previously provided for critical long-term needs of not only those with psychiatric conditions, but those with neurological conditions as well. Prison health systems must accommodate for the high prevalence of neurological impairment of female prison inmates who have often also been victims of childhood abuse. It is critical to break the cycle of events in the ongoing downward spiral related to the lack of regard for self and others, which leads to high risk behaviors for recurrent TBI and contributes to life-long neurological decline. Because female prison inmates in this population often receive short sentences and are frequently incarcerated and released, prison health systems could play an important role in helping to break the cycle contributing to ongoing neurological decline. Screening for neurological impairment and attempts to separate patients with some neurological disorders from other prisoners may help the vulnerable population of female prison inmates from being exposed to criminal role models, further injury, and/or violence contributing to exacerbations of their condition. Prisons provide public health opportunities to reach medically underserved communities in the United States . Yet health care systems alone cannot resolve this multifactorial problem. Wildeman and Western argue that criminal justice reform alone will not solve the issues related to school failure, joblessness, untreated addiction, and mental illness that lead to increased incarceration; and that criminal justice reforms alone would repeat the mistakes made in the United States during the prison boom by addressing serious social problems with criminal justice policies. These problems require greater commitments to education, public health, and employment opportunities of low-skilled men and women . Mental health is a critical area that requires serious attention in order to address incarceration rates and their long-term consequences for fragile families that contributes to ongoing neurological decline. Nurse mentoring can play a role in this vulnerable population of children with incarcerated parents with public health initiatives to address high-risk behaviors in this often forgotten segment of the population . Further research is needed to determine the best interventions to rehabilitate those who have sustained a TBI in order to prevent neurobehavioral problems resulting in incarceration, recurrent TBI, and to prevent life-long neurological decline in this vulnerable population of children throughout their life span. --- Conclusions Our findings have international implications as neurological decline is projected to be an increasing world-wide public health threat in aging populations . It is critical to recognize those at risk in order to plan prevention efforts. Parental incarceration impacts the long-term neuro-behavioral health of children. Along with being role models, adult family members promote a safe environment contributing to the physical, emotional, and neurological health of children throughout their lifespan. Children in extended families with incarcerated adults are a vulnerable population where initiatives are critically needed to prevent long-term consequences including life-long neurological decline. This is especially true for disproportionately higher rates of Black and Hispanics in the United States. Those who work with these children can play an important role in teaching them coping skills to prevent emotional and behavioral disorders, and improve resilience to adversity to prevent the cascade of events contributing to ongoing neurological decline. Children with incarcerated adult family members need support from their community. Particular attention is needed to help prevent high risk behaviors due to lack of regard for self and others that results in ongoing neurological decline throughout the life span of vulnerable populations of adult children of incarcerated adult family members. Those with incarcerated adult family members during childhood experienced greater frequency and severity of childhood abuse than those without incarcerated family members. Those with incarcerated adult family members during childhood had greater neurological deficits on physical examination than those without incarcerated adult family members.

A secondary analysis of data from adult female prison inmates in the mid-Atlantic United States defined relationships between having incarcerated adult family members during childhood and neurological outcomes. Of 135 inmates, 99(73%) had one or more incarcerated adult family members during childhood. Regression analyses revealed that having incarcerated adult family members was related to greater frequency and severity of childhood abuse and higher incidence of neurological deficits in adulthood, especially related to traumatic brain injuries, compared to those without incarcerated adult family members. Along with being role models, adult family members impact the neurological health of children throughout their lifespan. With the projected increase in prevalence of neurological conditions in the growing aging population in both developed and developing countries (WHO, 2015), it is critical to define risk factors in order to target prevention strategies. With the growing rate of incarcerations, it is critical to understand the impact this has on children in the families of incarcerated adults. Most studies of children with incarcerated adult family members describe psycho-social outcomes, yet little is understood about the long-term neurological health implications of having an adult family member incarcerated during childhood. The aim of the researchers was to elucidate the impact of having incarcerated adult family members during childhood on females and to define associated neurological health throughout their lifespan. The purpose of this study was to test our hypotheses that having incarcerated adult family members during childhood places one at greater risk of becoming a victim of abuse and increases risk for neurological impairment that results in ongoing high risk behaviors leading to subsequent incarceration and neurological decline throughout the life-span of females.

Career, Family, and Workforce Mobility: An Interdisciplinary Conversation This paper focuses on how two disciplines, sociology and career development, make visible different aspects of the complex, intertwined and dynamic phenomena of career, family and workforce mobility. An abundant literature in these fields has acknowledged the ongoing challenge in understanding how the individual, family and employment cohere in postmodern times . Despite this extensive literature, the work on boundaryless careers, and the connection of this work to an understanding of mobility between organizations , both disciplines are yet to fully integrate issues of labor market mobility within theorising on work and career, the worker and family. To move in this direction, this paper integrates concepts from both disciplines, including the concept of mobility from the sociology literature, and the increasing relevance of constructivism within the career development literature. In acknowledgement that some of these concepts will be new, they will be explained initially to set a context for the reader. Urry critiques much social science as "a-mobile" , arguing that the mobility turn offers "a different way of thinking through the character of economic, social and political relationships" . Urry's concept of mobility focuses on the development of sociality and identity through networks of people, ideas and things which are always moving and changing. Cresswell describes this mobilities paradigm as acknowledgement of increased levels and forms of mobility in the world, leading to "a kind of thinking that takes mobility as the central fact of modern and postmodern life" . The focus here is on mobility in the "horizontal" sense of spatial relocation rather than the "vertical sense" of social mobility , career advancement , or change of employer . These two dimensions can become intertwined when considering workforce mobility. In the sociology literature, the new mobilities paradigm emphasizes how movement is central to many lives and many organizations. Similarly, researchers in the field of career development have become interested in the increasing influence of globalization and labor market mobility on individuals' career decision-making . A contextual worldview is increasingly underpinning the theoretical base of career development . This worldview emphasizes the importance of the multiple layers of an individual's context in individuals' career decision-making. Proponents of this worldview critique the ongoing focus on career and work relationships as being relevant only to individuals and somehow analytically separable from other relational structures and intersubjective ties. Rather, the contextual worldview emphasizes the crucial nature of an individual's multiple and complex relationships and intersubjective ties which loom large in career decision-making. Within this worldview, careers are constructed within familial, social, historical, cultural, geographic and socio-political systems in which individuals live . This current article contributes to the special issue in focusing on a broader conceptualization of career mobility, and in describing conceptually the importance of family and workforce mobility as factors relevant to both individual and organizational career growth. By synthesizing aspects from both the sociology and career development literatures, this article highlights the importance of family as the prime unit of analysis to understand the mobility choices and dispositions of individual workers and the impact of these decisions on organizations. It therefore emphasizes the importance of attending to the relationships between individual factors and organizational factors in career growth and organizational growth. It is often whole families which are made mobile and it is a family which needs to reconstitute lives in multiple institutions. First, this article documents the growing imperative to be mobile within the context of changes and challenges in more global workplaces and explores calls for a greater interdisciplinary approach to examining career. The article then reviews conceptual and empirical literature from both sociology and career development to identify common ground and possible articulations. The thesis of this article is that in a changing world of work, governments, organizations and associated fields of scholarship need to embrace broader considerations with regard to expectations of workforce mobility. Despite workforce mobility having both individual and organizational impetus and outcomes, it is often the family which bears the brunt of workforce mobility. It is noted early in this article that the literature in this space to date has focused on heterosexual families and that attention needs to focus on other families. --- The Context: Changing Global Workplaces and the Mobility Imperative Population mobility has become an attractive policy goal for nations, organizations and corporations to protect economic competitiveness and to foster productivity, flexibility, and responsiveness. For example, a recent inquiry by the Australian Productivity Commission , a key Australian government advisory body, builds from the premise that labor mobility is an important element of a well-functioning, efficient and flexible labor market. Its authors argue that, by improving the match between employers and workforce, geographic labor mobility can contribute to economic efficiency and ultimately to community wellbeing through higher incomes. The authors of Deloitte Australia's These Deloitte projections accord with those in the Price Waterhouse Cooper's report, Talent Mobility 2020 . PWC predicts a significant shift in mobility patterns as workers from emerging markets operate more globally, producing a noticeable change in the global talent pool and its flows. Although technology might play a key role, the authors note it will not "erode the need to have people deployed on the ground" . The PWC report also highlights the greater sophistication and complexity of mobility assignments and the need for strategies which will meet changing career and workforce expectations of organizations and employees. Workforce mobilization extends within and across national boundaries. Strategies of economic regionalization have scaled up labor markets by reducing barriers to movement to allow people and businesses to pursue opportunities emerging elsewhere. Globally, these strategies include financial incentives for organizations and ease of international movement for workers. Within countries, a number of strategies such as housing, employment tenure, and schooling preferences for children are employed to incentivize workers to move to less favorable locations. However, there is evidence that some of these schemes to mobilize people have failed to attract sufficient numbers of workers for meaningful lengths of time. A number of international reports have demonstrated the importance of family considerations in career decision-making which includes workforce mobility. A European Commission report noted that while the majority of Europeans think moving is good for the economy, the labor market, and individuals, fewer think it is good for families. Similarly the Canadian Employee Relocation Council's Global Mobility Survey , reporting data from 24 countries, found that family and young children are cited as the main barriers to mobility. The Australian Productivity Commission reported that government schemes to move professional workers into rural and remote areas had limited effect. Doherty, Shield, Patton & Mu emphasized that with the considerable problems involved in moving for all family members, incentives offered by government and organizations need to be cognizant of individual life cycle circumstances rather than presumed cohort attractions and benefits. As the 21 st century world of work increasingly implicates mobility as part of career opportunity, so mobility is relevant to career decision-making. New theoretical understandings in career development psychology emphasize the importance of an individual's context, especially family, as a key influence in career decision-making. This interconnectedness challenges our field to develop interdisciplinary responses to understanding these phenomena. The next section will introduce calls for interdisciplinary approaches, and in particular the imperative to connect concepts from sociology and career development psychology. --- An Interdisciplinary Approach to Careers Collin outlined the multi-dimensional and multi-layered nature of career as a lived phenomenon, commenting that studies of career need to reflect this complexity. Broad conceptualizations of career studies embrace a wide array of disciplines including philosophy, economics, psychology, organizational behaviour, industrial psychology, personnel selection and retention, vocational education, psychiatry, sociology, education, industrial relations and human resource management. However, scholars continue to pursue questions about career from within their own disciplinary theoretical and methodological frames, resulting in a separation and lack of exchange . There have been multiple calls for a greater connection in career studies . In particular Dany commented "Keeping in mind that careers unfold in inhabited worlds could help to have both convergence and diversity to sustain the integrative approach we are calling for" . Collin drew an important distinction between multidisciplinarity, interdisciplinarity, and transdisciplinarity: With multidisciplinarity, several disciplinary perspectives come together to work independently on the same problem, and are unchanged in themselves when they disperse. With interdisciplinarity, their collaboration may result in the building of bridges between them or, going even further, integration between them and the formation of a new, hybrid, discipline . Collin then defined transdisciplinarity as "the use of theories, concepts, and approaches from one or more disciplines as an overarching conceptual framework to address issues in a number of disciplines" . Using these definitions, the conjuncture of disciplinary approaches presented in this paper demonstrates an example of interdisciplinarity, provoked by a complex object of study, and precipitated by an interest in the processes on the individual's side that make workforce mobility thinkable and doable. Practitioners of a sociology of reflexivity treat intra-individual deliberations as a social phenomenon, while a contextual approach to career development demands attention to context and related influences. In this way the sociological and psychological gazes extend and intrude into each other's traditional territory, because the research problem demands a complex response that neither discipline can deliver alone. --- Thinking from the Field of Sociology The mobility turn in sociology can articulate with other work that has probed the growing demand for reflexive negotiation between individuals, their relational ties and their social context, to illuminate strategic life decisions such as career mobility. Beck's thesis of "institutionalised individualisation" argues that, through global waves of neoliberal policy, governments have divested themselves of the responsibility to provide default social structures for the population as a collective, instead transferring responsibility onto families and individuals to make their own way. For example, families with children need to make specific investigation into choice of school as previous assumptions that all government schools provide the same educational opportunities can no longer be guaranteed. Beck and Beck-Gernsheim extend this perspective to understand the impact of institutional individualisation on families, emphasizing that the erosion of predictable social scripts forces families to reflexively improvize how the family unit can work in its contextual circumstances. Mobility decisions thereby become one avenue for managing risk and optimizing life chances of individuals and families in an increasingly uncertain world. The increased complexity, however, is that these mobility decisions need to consider all family members, however institutions tend to engage with family members as individuals, not as a cohesive unit. Archer's sociology is interested in the internal conversation that weighs up opportunities and risks presented in the social context to design life projects, because this is the process that mediates between society and the individual. Archer notes how structural constraints and enablements deter or encourage certain projects, so any outcome is the result of the interplay between the individual's agency and what their social context enables, that is "reflexive projects" . The response by individuals is not just rational choice. Rather it is emotional, tapping their deep concerns. Archer uses the term "dovetailing" to capture the way these occupational concerns must mesh or accommodate family concerns. The sociology derived life course perspective has provided a scholarship in which "careers extend beyond occupational concerns and into other aspects of people's lives, such as family careers and marking progressions through family forms and structures" . Moen and Sweet drew on this perspective to frame their discussion of work and family, moving the discourse from one of individuals to a focus on dynamic relationships between roles and among individuals as lives unfold -over time; in tandem; and in particular contexts. These authors emphasized the need to move away from the workfamily dichotomy to focus on the complex interface among social structures, social changes and individual biographies which are careers. They emphasize the contextual changes which highlight the disjunctures where careers intersect with existing gender, occupational, labor market and workforce changes. Family, work and mobility. While there is an expanding sociological literature regarding the family/work interface , there has been less focus on family/work and mobility, although some empirical work has tracked the emergence of new spatial arrangements for family households precipitated by work demands or opportunities. The embeddedness of individuals and families in existing work contexts and in social networks has been identified as deterrents to whole of family relocation , so families are experimenting with new residential arrangements to achieve stability for children and access to mobile career opportunities. Levin described the "new family form" of "living apart together" . Van der Klis and Karsten considered the gender imbalance of "commuter families", which "enable parents to seize distant work opportunities and preserve solid local roots for family life" . Schneider and Limmer highlighted the growing demand for job-related mobility of various scales in Germany and its impact on family and community life, while Haslam McKenzie documented the "fly-in fly-out" family form in remote Australia, whereby typically the male partner works in a remote location with little social infrastructure over a compressed working period, returning to the family home for breaks. Green initially documented the long commuting solution adopted by British dual career families to keep the family together; but, in more recent work, Green reported the emergence of "dual location households" . Luck and Ruppenthal compared the "mobility culture" of different European nations and birth cohorts, while Hardill documented the contingent trade-offs within the family unit when transnational career opportunities present. Gendered implications of mobility. At the macro sociological scale, these solutions have raised concerns about their reinvigoration of an asymmetrical, gendered division of labor in the home and the further entrenchment of traditional female roles . The impact of family mobility on women's careers is well documented. Bielby and Bielby reported that wives are more likely to relocate for the sake of their husband's job than for their own, although Pixley reported that this trade-off is related to respective income levels. Roberts emphasizes that "Women's family careers often disrupt their employment careers", in particular in the way "some women's careers had been unhinged by needing to relocate because their husband's jobs required this" . The well documented "trailing spouse" pattern also highlights how it is more typically the female parent who compromises her career stakes in the collective's interest. Haasler confirms that women in dual earner households are still responsible for managing the households, especially if they also have young children. --- Families with children. Families with children, especially when they reach school age, have another layer of complexity to work through. Studies that document how jobrelated mobility can relocate the worker away from the family home implicitly demonstrate the normative reluctance to relocate households with school-aged children . There is some evidence that whole family mobility can be detrimental to schooling outcomes . An Australian study provides data on whole family relocations . Their sample included military personnel and core public service professionals in Australia, groups for whom career progression is often conditional on frequent mobility. For these families, this strategy of whole family mobility typically worked until children reached critical junctures in their education. At this point, the military interviewees described how family priorities tipped, sometimes at the expense of military career advancement, other times at the expense of the military career itself. However, the public service professionals understood the mobility expectations within their career structures and were largely able to plan for broader family educational considerations. However the existing literature largely fails to account for those families who choose to remain together while on the move for career purposes. Taken together, these different sociological studies thus fail to account for the conundrum at their intersection: how the immobility/stability typically valued for children can at times be set aside in the pursuit of an individual family member's career opportunities. There is a crucial process of intersubjective bargaining and risk calculation within family units that mediates individualized career strategy. The new mobility paradigm in sociology, in conversation with other social theory, can inform not just greater understandings of mobility patterns and their differences, but also reveal how families are constituted in and by the web of accommodations and intersubjective bargains that both enable and constrain the individual's career project. The next section reviews literature from the discipline of career development psychology to examine these phenomena through a different disciplinary lens. --- Thinking from the Field of Career Development The field of career development has been challenged for its theoretical focus on intraindividual influences to the neglect of the broader environmental context . This focus has prevented a stronger analysis of the individual's relational connections. However, it is increasingly being recognized within the career development psychology literature that an individual's career is impacted not just by the macro societal context in which they live, but also by the micro social circumstances that emerge as work and family lives intersect. A contextual worldview emphasizes that how events are viewed is linked to the perspective of each individual, with development conceived as an ongoing process of interaction between the person and their environment. Career work within the contextualist worldview focuses on individuals interacting with multiple intrapersonal influences and with those from their social and environmental contexts. A number of theoretical discussions have developed from this worldview. Collin raised the concept of the "family friendly career" and advocates for a systems approach to conceptualize a family friendly career in increasingly mobile times. Drawing on systems theory, Patton and McMahon developed the metatheoretical Systems Theory Framework of career to demonstrate the importance of all levels of an individual's system and the relative influences of these levels on an individual's career. The STF is composed of several key interrelated systems, including the intrapersonal system of the individual, the social system and the environmental-societal system. The processes between these systems are explained via the recursive nature of interaction within and between these systems, change over time, and chance. The individual system is composed of several intrapersonal content influences which include gender, age, self-concept, health, ability, disability, physical attributes, beliefs, personality, interests, values, aptitudes, skills, world of work knowledge, sexual orientation, and ethnicity. Influences representing the content of the social system include peers, family, media, community groups, workplace, and education institutions. Environmental-societal system influences include political decisions, historical trends, globalization, socioeconomic status, employment market, and geographical location. Family and work decisions. In expanding on their notion "family relatedness of work decisions" , Greenhaus and Powell emphasize the relevance of family to a large number of work decisions. They also note the relationship between family situations and work decisions, and in particular the effect of context in which individuals live, explaining that these contexts will affect work decisions differentially for each individual. Echoing the systems identified in the STF, these authors identify individual context, the organizational context, and the societal context. However, there is little attention specifically to mobility related family career decisions in the work of Patton and McMahon and Greenhaus and Powell. A number of authors have extended the field's understanding of relationships and career development , emphasizing that their theoretical ideas have been derived in particular from what they term the 'relational cultural paradigm' . The term relational in career development is largely associated with the assumption that humans are relational beings for whom developing and sustaining meaningful connections with others is a core activity. In contrast, thinking relationally is built into the sociological gaze that will orient to the constitutive relations built into structures, categories and fields. It is not just between people . --- Influence of changing social context of work. In addition to these reconceptualizations, much of the social context of work has been changing, forcing a rewriting of previous understandings of career processes . The emphasis in the emerging 21 st century career has shifted from the organization to the individual, and as such has reinvigorated the emphasis on the individual in discussions of career . This shift is reflected in new notions of 'protean' and 'boundaryless' careers . The concept of protean career refers to the notion that, to adapt and survive in a changing world, the individual needs to be self-generating; that is, protean, managing the intersection between self-organizing and social phenomena, or "in charge of his/her own career" . However, this theoretical work again de-emphasizes the important role of context and in particular family in career decision-making . A more relational, intersubjective lens emphasizes the interface between adults, work and relationships in multiple ways. Women's careers. Although much of the career development literature has focused on work-family conflict and stress for both women and men in managing competing roles, empirical work overwhelmingly suggests that women remain more likely to change their career paths and forego workplace opportunities because of family responsibilities . Although governments in many Western countries have implemented key policy levers in support of both male and female participation in the workforce, such as family leave, child care support and flexible work arrangements, these have been introduced more in connection with pressures for all citizens, women and men, to be economically independent. Schultheiss and Richardson and Schaeffer critique such policy as privileging paid market work over unpaid work, such as caring for children, ageing parents and other loved ones, especially at a time when care of the elderly is a pressing social issue. While the mobilities turn in the social sciences ) has impacted a number of disciplines, this brief review has indicated that the application of mobilities studies to career development is less evident. Within this literature, the focus has been on boundaryless careers , and identifying a definitional focus for career change in terms of job change, organizational change, occupational change and career mobility . Mobility in this field refers more to change within a professional field, change across occupational groupings, and change which may include geographical mobility -short or long term, national or international -within individuals' careers. The challenge for this field is to account for how multiple factors interact to produce or deter spatial mobility. While analytically each factor offers some explanatory power, ultimately the phenomenon is explained in how these facets cohere and dovetail in lived experiences of individuals and families. --- Future Research: Interdisciplinary Themes The conceptual and empirical literature from both sociology and career development acknowledges the challenges involved in understanding career mobility as the complex interplay between labor market, workplace mobility, individual and family. However, both fields of scholarship are yet to fully explore this new nexus. This section offers key themes for future research from this brief interdisciplinary theoretical and empirical conversation, and proposes fields of inquiry for research. These themes include: the pressure the mobility imperative places on women's domestic and family roles and the gender balance in intersubjective compromises around career mobility for dual career couples; the influence of children in families' career mobility decision-making; and different rationales and improvisations around career mobility. Finally this section proposes some methodological considerations. --- Women's Careers, Family and Workforce Mobility The impact of the family career on the female career has been documented in both literatures ), with the compromise in paid work and career progress primarily being made by the female, even when there are no children. The international studies reported in Bimrose et al. document the extensive and complicated nature of the interaction between women's unpaid and paid work experiences. Similarly, research has consistently shown that it is most often the women's career trajectory which is compromised when a mobility opportunity presents itself . Although Pixley reported data that income levels may moderate this , most documented literature continues to present the traditional view. As the nature and structure of the workforce continues to change, and with the expectation that women's career projects will come to exert more priority in family decisions, research into career decisions of women and men over the life course, and in particular in relation to mobility decisions, will be vital for understanding relevant influences. Such data will also be highly important for individuals deliberating on career mobility, and for organizations developing policy frameworks for women's careers, and for working to attract and retain a mobile talent. --- Families with Children and Workforce Mobility It has been documented from both sociology and career development perspectives that families with children, especially school-aged children, face significant barriers with respect to mobility if they prioritize educational opportunity for their children . Doherty et al. showed how mobile children could accrue cumulative educational complications from institutional discontinuities over their family's mobility history. Similarly this research demonstrates that parents modified their own career aspirations and therefore income potential to protect the stability of their children's education. Such impacts of worker mobility absorbed by children and the family unit have received scant attention within both the sociology and career development literature and would be worthy of additional research. A focus on the family unit living mobility highlights the intersubjectivity of this social unit and the compromises being made by all members. These data derived from all family members would again assist organizations to prepare attractive packages to attract mobile workers. In addition, tracking the educational progress of children of mobile families would assist in understanding this phenomenon further. --- Family Strategies to Accommodate Workforce Mobility A third theme emerging in both literatures is the family strategy and improvizations around mobility, through different family models or workable solutions. Families are experimenting with new residential arrangements to achieve stability for children and access to mobile career opportunities, such as "dual location households" and "fly-in fly-out" solutions . Further research could monitor what costs and benefits accrue to the family and society more broadly under these improvizations. For example, research needs to examine work and career related outcomes , in addition to individual and family matters with respect to attachment, family connectedness, well-being and stressors of each family member experiencing these divided households. These data, when compared with family members experiencing whole of family mobility, would assist organizations drawing on mobile workers to develop support strategies. These data would also assist in understanding career decision influences. Career mobility is not always about moving on to get ahead. Doherty et al. demonstrate that both the military personnel and the professionals in their study recognize that mobility was helpful for career progression. However there are other drivers for and against mobility. Much labor market mobility planned by organizations is only designed to provide short term labor for particular project needs. In this way, mobility decisions for individuals and their families might be about achieving or maintaining employment, or enriching family life, not just career advancement. There are additional risks and uncertainties in more speculative career mobility that warrant further research. --- Methodological Considerations for Research This review of these literatures emphasizes the importance of learning from paradigms that intersect around research problems, and developing an inter-or multidisciplinary focus for career mobility research . This more complex theoretical mix could accommodate and profit from both a range and a synthesis of research methodologies from both disciplines. The empirical studies reviewed in this article included interviews with individuals and couples at different life and career stages, narrative enquiry and surveys -some asking point in time questions, and others asking respondents to reflect back on key mobility decision points. Doherty describes a method of narrative interviewing of family members, and the construction of an orchestral score which provides a visualisation device for documenting narrative data. Incorporating a focus on family challenges the individualism inherent in many considerations of career and labor market mobility. Whole of family research highlights the relationship between mobility and family stages, in particular the life stages of children. Other areas which demand a focus include investigating family pressures for elder care, and examining all family forms . The dimension of time, or timing, in terms of life course or family phase, would enrich any understanding of career mobility . Such a research agenda will need a diverse and adaptable methodological toolkit, less devoted to disciplinary purities and more devoted to the research problem. From the field of career development, Blustein emphasizes that "one might need to sacrifice precise linear models for the complex, murky nature of working life that exists among family commitments, shifting political factors, radically transforming economic structures, and complex and nuanced cultures" . Blustein calls for research to move beyond quantitative surveys and to pursue narrative as a research approach, although Holdsworth suggests narrative may be problematic in gathering data from children and adolescents. From the life course sociology literature, Moen and Hernandez describe strategies and techniques for "capturing the embeddedness of individuals within the lives of others as linked lives at any one point in time and as social convoys over time" . They note the need for social groupings and relational units as prime units of analysis, rather than the individual, and suggest gathering individual variables in addition to couple-level variables. These authors propose gathering family longitudinal data as follows: household composition, household income, age and education, styles of decision making, family conflict frequency, and nature and frequency of social network contact. --- Concluding Comments This exploration of conceptual and empirical work from two disciplinary fields has demonstrated that the complexities of family solutions to career mobility undo the apparent simplicity of delivering a worker to a new worksite. Although organizations and governments work to develop policies that incentivize mobility, including transport infrastructure, housing, employment conditions and tax incentives, these will not necessarily address the private concerns and priorities of families. Within a world where career opportunities increasingly implicate mobility, this article has focused thinking around this influence through the disciplines of sociology and career development. It is evident that each field could learn from the other, and we suggest that socially complex problems such as workforce mobility will benefit from multidisciplinary conversations which articulate and mesh theories and methodologies from each field. Indeed Cresswell has argued that "Mobilities research has linked the fact of movement across scales and in a way that links the humanities at one end to the sciences to the other" . Current mobilities research includes scholars from multiple fields , and the fields of sociology and career development discussed in this article are but two. More integrative work, incorporating theorizing and methodologies from both the humanities and the sciences, will contribute to a maturing of our understanding of the complex interaction between individual, family and the social and economic contexts in which careers develop.

The purpose of this article is to synthesise conceptual and empirical work from the fields of both sociology and career development to explore how issues of career, family and workforce mobility are necessarily interrelated. The use of work from sociology and career development demonstrates that the complexities of family solutions to career mobility undo the apparent simplicity of delivering a worker to a new worksite. Although organizations and governments work to develop policies that incentivize mobility, including transport infrastructure, housing, employment conditions and tax incentives, these will not necessarily address the private concerns and priorities of families. The article argues for an interdisciplinary approach to better understand the intersubjective complexities implicated in the growing phenomenon and expectation of worker mobility, and suggests both areas and design strategies for further research.

Despite the gradual decline in the prevalence of smoking over the past half century, smoking has persisted as the number one cause of preventable deaths in the USA. Smoking is significantly linked to several cancers, as well as various cardiovascular, metabolic, and pulmonary diseases [1]. Smoking cessation is associated with reduced risk of cardiovascular disease among heavy smokers [2] and reduced mortality risk among individuals with coronary heart disease [3]. Some individuals, however, those we call recalcitrant smokers, continue to smoke despite having smoking-related conditions. For example, twothirds of cancer survivors continue smoking after cancer diagnosis [4] and, after having a myocardial infarction, around half of the smokers continue smoking, even though this is linked to adverse health impacts and low quality of life [5]. Vulnerability to nicotine addiction might be a reason why some individuals with such adverse health conditions continue smoking [6], yet cumulative evidence shows that low socioeconomic position and stressful experiences are well-known predictors of the initiation and cessation of smoking, as well as relapses [7,8]. Such life circumstances that affect smoking habits may originate in early life [9][10][11]. The association between early-life adversities and recalcitrant smoking might be transmitted through life-course factors, yet we are aware of only one study that has tested such a hypothesis [12]. Some early-life adversities are more strongly and adversely tied to adult health for women than men, for example, the link between child abuse and laterlife mortality [13]. However, we have little knowledge of whether women and men respond differently to early-life adversities in terms of the likelihood and mechanisms of smoking recalcitrance. To shed light on these issues, we investigate to what degree early-life adversities are associated with the risk of recalcitrant smoking, psychosocial factors that explain the association, and gender differences in any observed associations. --- Background Early-Life Adversities and Smoking Early-life adversities include a host of negative experiences that may occur in childhood. Low socioeconomic status , family instability, and abuse are among the most commonly occurring early-life adversities that we know of [14][15][16]. Such early-life experiences affect health and well-being throughout the life course, including the risk of smoking behaviors. For example, growing up in a low-SES family increases the risk of smoking initiation and the likelihood of smoking in adulthood [9]. For women, experiencing physical or sexual abuse in childhood increases the risk of regularly smoking cigarettes by 14 years of age [10] and of smoking in early midlife [11]. Similarly, exposure to family instability, such as growing up in divorced families, increases the risk of smoking and the number of cigarettes smoked for women [17]. Few studies, however, have investigated whether early-life adversities are associated with more harmful smoking behaviors, such as smoking despite having a serious medical condition. Only one study, to our knowledge, has found a significant dose-response association between early-life adversities and smoking among individuals who have smoking-related illnesses and symptoms, including heart disease, chronic lung disease, and diabetes [12]. This study was based on a community sample of adults who completed a standardized medical evaluation at a Health Maintenance Organization, so the findings may not be generalizable to broader populations. Additionally, this prior study focused on a cumulative number of exposures of all observed adversities [12], thus offering no insight into the unique effect of each domain of adversity . Moreover, its use of cross-sectional data obviated the possibility of investigating extensive life-course pathways linking early-life adversities to recalcitrant smoking. --- Gender Differences in the Effect of Early-Life Adversities Women might be more vulnerable than men to early-life adversity in terms of later-health outcomes, although the association varies by type of adversity and health outcome. For example, women, but not men, who experienced parental divorce in childhood smoked more [17]. For women, but not men, childhood abuse increases the risk of later-life mortality [13]. An inverse association between childhood SES and later-life body mass index is stronger for women than men [18]. Yet, men, but not women, who grew up in low-SES families are more likely to consume unhealthy foods in midlife [19]. No study has yet examined gender differences in the association between early-life adversities and recalcitrant smoking, yet we have reason to believe that gendered patterns exist. A long line of research about boys' sensitivity to economic hardship leads us to speculate that males' smoking behaviors might be more affected by low childhood SES. Boys are more adversely affected by growing up in economically deprived households, including experiencing less hopefulness, self-esteem, and confidence about their future [20,21]. In response to their increased vulnerability to economic hardship, boys tend to act out with more disruptive behaviors rather than with an emotional response, which may, in turn, increase harsh parental discipline for boys but not girls [22,23]. Due to harsh parenting practices and rejection from parental figures, young boys may be more likely to turn to peer groups that encourage more socially disapproved acts, such as smoking [24]. Such unhealthy behaviors established in early life may continue into later life. In contrast, family instability and abuse in childhood might have unique consequences for women's smoking. Both family instability and childhood abuse are connected to impaired interpersonal relationships during adulthood [25,26], and the adverse impact might be stronger for women than men [27,28]. Gender differences may stem from highly gendered socialization processes during childhood where the differential emphasis is placed on closeness with others. Sex role theorists contend that girls, but not boys, are socialized to place great emphasis on forming and maintaining close interpersonal ties with others [29,30]. As a result, interpersonal relationships may originate from and cause emotional experiences for girls significantly more than for boys, and this may extend into adulthood [31]. Women are more likely than men to believe that smoking can be used to manage negative emotions and act as a coping tool for previously experienced stressors [32]. Therefore, unstable and abusive relationships in childhood may increase the risk of recalcitrant smoking for women. --- Potential Pathways Linking Early-Life Adversities and Recalcitrant Smoking Cumulative inequality theory suggests that adversities during childhood shape opportunities and risks over the life course, in turn, affecting later-health outcomes [33]. The life-course pathway model [34] suggests that earlylife circumstances may influence subsequent material, social, and psychological life-course factors that may contribute substantially to the risk of smoking behavior. There is a well-established association between earlylife adversities and decreased psychological well-being, usually in the form of depressive symptoms that extend decades beyond early experiences [35]. Studies based on clinical samples found that, among cancer patients, depressive symptoms are a significant predictor of persistent smoking [36] and smoking relapse [37]. Therefore, depressive symptoms could be an important pathway linking early-life adversities to recalcitrant smoking. A prior study, however, found that the mediating role of depression is not large [12]. Other life-course factors may help us understand why experiencing early-life adversities is associated with recalcitrant smoking, for example, adult SES. Individuals who experienced early-life adversities are less successful in school and in the labor market [38], and they have more financial difficulties in later life [39]. Compared to individuals with high SES, those with low SES are more likely to smoke and less likely to quit smoking [7]. Some studies have found that, after adjusting for adult SES, the association between childhood SES and adult smoking is attenuated to nonsignificance, suggesting that one's adult SES may be significantly associated with current smoking more so than childhood SES [40,41]. Moreover, childhood adversities can lead to further hardships and stress exposures in later adulthood [42]. Psychological stress, including exposure to stressful life events and chronic and financial strain, is associated with the persistence of and relapse into smoking behaviors [7,43]. A recent study has shown that stressful events impacting family members are also associated with smoking in midlife [8], indicating the important role of network stress on an individual's health behaviors. Another important intervening mechanism is an individual's motivation to quit smoking, which may be bolstered by social support. Studies have found an association between high SES and smoking cessation possibly through desire, intention, or sense of duty to stop smoking [44]. The observed associations may, in part, be attributed to individuals from low SES having lower levels of purpose in life [45]-a psychological asset that helps individuals prioritize long-term goals over immediate ones, such as engaging in unhealthy behaviors [46]. Moreover, social support best helps individuals stop smoking when the support is consistent and nondirective [47]. Yet, individuals who experienced early-life adversities report lower levels of social support in adulthood, such as not having a spouse/ partner and decreased perceptions that one's family is supportive [26,48]. --- Hypotheses of the Current Study Based on this extant literature, we hypothesize that early-life adversities will be statistically significant predictors of the risk of individuals' recalcitrant smoking . We expect that some early-life adversities will be more influential for women than men. Specifically, we hypothesize that socioeconomic disadvantage will be more strongly associated with the risk of recalcitrant smoking for men than women , while unstable and abusive relationships in childhood will be more strongly associated with the risk of recalcitrant smoking for women than men . Using selected psychosocial factors from the literature, we then test Hypothesis 3: psychosocial factor will mediate the positive association between early-life adversities and recalcitrant smoking. Given that little is known in terms of predictors of recalcitrant smoking, throughout these analyses, we pay close attention to those life-course factors that are significantly associated with recalcitrant smoking, as well as gendered patterns in the associations. --- Method Sample Data for this study come from the Midlife Development in the United States study, a national survey designed to assess the role of social, psychological, and behavioral factors in understanding differences in mental and physical health . MIDUS began in 1995-1996 with noninstitutionalized, English-speaking adults aged 25-74 in the 48 contiguous states [49]. National random digit dialing with oversampling of older people and men was used to select the main sample and a sample of twin pairs . The study also includes a random subsample of siblings of individuals in the main sample and oversamples from five metropolitan areas in the USA . MIDUS consists of a two-stage survey: a telephone interview and a self-administered questionnaire. Approximately 89% of the sample completed the two-stage survey at Wave 1 . Follow-up interviews with MIDUS respondents were completed in 2004-2006 . The longitudinal retention rate for Wave 2 was 75% after adjusting for mortality. Additional information about sampling, enrollment, and longitudinal retention is documented elsewhere [50]. The present analysis uses data from the 4,932 individuals who participated in both the initial and the follow-up survey . Compared to individuals who died or were lost to follow-up at Wave 2, those who participated in both waves were more likely to be white, female, married, more highly educated, and to report having better health. This attrition may result in selection bias between Waves 1 and 2. --- Measures Early-life adversities include socioeconomic disadvantage, family instability, and parental abuse. By maximizing available information in MIDUS, we created the index of low childhood SES , which is an average of standardized scores of six indicators: mother's and father's education , mother's and father's occupational prestige score as measured by Duncan's Socioeconomic Index [51], welfare status , and financial level growing up . Family instability is a binary indicator based on the question, "Did you live with both of your biological parents up until you were 16?" Possible reasons for a negative response include parental death, separation or divorce, parents not living together, and never knowing a biological parent. For childhood abuse, respondents were presented with a battery of items from the modified version of the Conflict Tactics Inventory [52]. Respondents were asked how often they had endured each of the following forms of abuse, which fall into three lists/domains: List A , List B , and List C . List A includes items related to emotional abuse, while items in Lists B and C represent physical abuse. The response options included 1 = never, 2 = rarely, 3 = sometimes, and 4 = often. The correlation between emotional and physical abuse was .73. By averaging the 15 items , we created an index of childhood abuse . --- Recalcitrant smoking in midlife To identify recalcitrant smokers, we followed the threestage process described in Fig. 1. We first obtained smoking status through a question at Wave 1 . Next, we identified those ever-smokers who developed or had at least one of the following illnesses or symptoms at Wave 2 that may be exacerbated by smoking: ever had heart problems suspected or confirmed by a doctor, ever had a heart attack, ever experienced or been treated for a stroke in the past 12 months, ever experienced or been treated for hypertension in the past 12 months, ever experienced or been treated for asthma, bronchitis, emphysema, or other lung problems in the past 12 months, ever experienced or been treated for diabetes or high blood sugar in the past 12 months, or ever had cancer. Finally, we identified recalcitrant smokers as those who have ever had smoking-related illnesses but indicated during the Wave 2 interview that they smoke regularly . The logic to identify recalcitrant smokers is consistent with prior work [12]. --- Life-course mediators Based on prior studies, we included six mediators linking early-life adversities to smoking status in midlife: education, financial strain, mood disorder, recent family problems, purpose in life, and marital or cohabiting status. For education, respondents reported their highest grade of school or year of college completed. Response categories ranged from 1 = no school/some grade school to 12 = PhD, MD, or other professional degree. The index of financial strain is an average of standardized scores of four indicators: current financial situation , control over financial situation , availability of money to meet basic needs , and level of difficulty paying bills . Mood disorder is a binary variable that indicates whether a respondent has major depressive disorder or generalized anxiety disorder. Both disorders were assessed through phone interviews that used the screening versions of the World Health Organization's Composite International Diagnostic Interview, Version 10 [53]. Major depressive disorder and generalized anxiety disorder were defined according to criteria specified in the third revised edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders . Consistent with prior work [8], we created an index of family problems using 30 items that capture whether three major family members had problems during the past 12 months in any of the following 10 areas: health, alcohol use, substance use, finances, work, school, job, legal issues, marriage, or other relationships. Response options were yes or no . We summed the scores from the three family members . A purpose in life index was created using a three-item version of Ryff's Scale of Psychological Well-Being [46]. On a scale from 1 = strongly disagree to 7 = strongly agree, participants responded to three statements: "I live life one day at a time and do not really think about the future"; "Some people wander aimlessly through life, but I am not one of them"; and "I sometimes feel as if I've done all there is to do in life." Purpose in life was the average of these three items . The low reliability of the index is due, in part, to the small number of items. Sensitivity analysis shows that substantial findings are consistent across a 7-item version in Wave 2 vs. a three-item version in Wave 1. Thus, we used the index from Wave 1 to ensure the temporal order between the mediator and outcome. Married/cohabiting is a binary variable based on a question asking whether the respondent was married or living with someone. We created family support using four questions reflecting positive relations with family members: "How much do members of your family really care about you?"; "How much do they understand the way you feel about things?"; "How much can you rely on them for help if you have a serious problem?"; and "How much can you open up to them if you need to talk about your worries?" Possible responses included 1 = not at all, 2 = a little, 3 = some, and 4 = a lot. Given that the average score of the four items was positively skewed, we created a binary indicator of high family support if the average score was equal to 4 . We included three demographic confounders from Wave 1, which are associated with smoking status: age as a continuous variable , race , and gender . Racial and gender statuses were created using selfidentified racial status and sex . --- Analytic Strategies Descriptive statistics were calculated using two-tailed t-tests for continuous indicators andχ 2 tests for binary variables. We used sequential logistic regression models to estimate the effect of early-life adversities on the risk of each of the three irreversible stages toward recalcitrant smoking: one must be a smoker , then develop a smoking-related illness , and then continue smoking despite having such a health condition . As shown in Fig. 1, these three stages consist of the following transitions. The first transition is a choice between being a smoker or not, the second transition is having a smoking-related illness or not among those who smoke, and the third transition is a choice between being a recalcitrant smoker or not among smokers who have a smoking-related illness. At each stage, the model predicts the effects of early-life adversities on the next transition using the sample from the prior transition as Stage 1: P = logit -1 , Stage 2: P = logit -1 and Stage 3: P = logit β 03 + β 13 X where βs are regression coefficients, logit -1 = exp 1+exp , and X represents early-life adversities. At the last stage presented, we created a series of nested models to investigate the life-course factors that explain why individuals exposed to early-life adversities become recalcitrant smokers. Given that we have multiple exposures to early-life adversities and mediators, we proceeded as follows. First, we estimated the effect of each adversity and life-course factor on recalcitrant smoking individually . We, then, added all three adversities together to investigate the additive effects of each adversity on recalcitrant smoking . If the additive effect of an exposure was significant, we examined the mediation effect of the exposure via life-course factors. In the following models, only the life-course factors found to be significant in the baseline models were added to Model 1 as potential mediators one at a time. The final model includes all exposures and mediators in order to examine the mediation effects via all combined life-course factors and to identify life-course factors, which have a significant effect net of other covariates. Coefficients from nested nonlinear probability models are not comparable because of unobserved heterogeneity-that is, the variation in the dependent variable that is caused by variables that are not observed [54]. Therefore, to ensure the comparability across nested models in logistic regression, we used the Karlson-Holm-Breen method [55] and, then, computed the percentage of the mediation effect relative to the total effect via each/ all mediators. The KHB method adjusts coefficients by separating the variation that is caused by omitted variables. To yield estimates comparable across predictors, all continuous predictors were standardized at the mean with the SD equal to 1. The analysis was stratified by gender, and gender differences in direct effects of Early-life adversities and indirect pathways were tested by pooling data from both genders and testing gender interaction terms. The sequential model, which we have used for a primary method, is a conventional model for addressing this type of dependent variable with multiple stages. However, this model cannot address possible selection biases due to excluding nonsmokers and nonsmokers and healthy smokers . To handle the possible selection biases, we used the Heckman model [56] as a sensitivity analysis. Given that the Heckman model only addresses two stages, we confined our sample to smokers and replicated the analysis of Stage 3 . The results from the Heckman model, which handles possible selection biases, are not substantially different from the results from sequential models . All control variables and mediators have 1%-2% of data missing on average. We handled missing data for these confounders using standard practices of multiple imputation [57]. To adjust for the possible selection bias between Waves 1 and 2 in terms of sociodemographic characteristics, we weighted the remaining sample by the inverse of the probability of dropping out given characteristics, such as race, gender, marital status, and education. Detailed procedures are provided elsewhere [58,59]. Robust standard errors were used to correct for intrafamily correlation given that multiple individuals are from the same family . As a result, all analyses employed multiple imputation, a poststratification weight, and robust SEs due to clustering. All analyses were implemented using Stata 15.0 [60], except gender differences in indirect pathways, which were analyzed with Mplus 8.0 [61]. --- Results --- Baseline Characteristics by Smoking Status As displayed in Fig. 1, 49% of respondents who participated in Wave 2 were identified as ever-smokers. Around half of them reported that they had at least one disease or symptom that might be exacerbated by smoking. Among respondents who had a smokingrelated illness, one-fourth continued smoking despite having such an adverse health condition. The prevalence of recalcitrant smoking was around 7% in the MIDUS sample . The likelihood of being recalcitrant smokers was slightly higher for women than men . Table 1 displays the results from bivariate analyses that tested whether all variables used in the analyses varied by the stages toward recalcitrant smoking. In the comparison between nonsmokers and ever-smokers , eversmokers were more likely than nonsmokers to have experienced low SES, abuse, and family instability in childhood. Ever-smokers tended to be male and older compared to nonsmokers. Among respondents in Stage 2, those who had a smoking-related illness were older and more likely to have experienced low childhood SES than those who did not have a smoking-related illness. Among respondents with a smoking-related illness , individuals who continued smoking experienced more adversities in early life than those who quit smoking. They also showed lower levels of resources that tend to inhibit smokingsuch as education, purpose in life, family support, and living with someone-and higher levels of risk factors of smoking, including financial strain, mood disorder, and family problems. Recalcitrant smokers, however, were more likely to be younger and female than those who quit smoking after having a smoking-related illness. --- Early-Life Adversities and Being an Ever-Smoker Table 2 shows the odds ratios and confidence intervals of the sequential response model at Stages 1 and 2 . We estimated the effect of each adversity in baseline models and, then, estimated the effects of all three adversities in the additive model. Results from logistic regression models in the association between earlylife adversities and ever-smoking are shown in Table 2 . In baseline models, we found that all three adversities were significantly related to an elevated risk of ever-smoking for both genders. When all adversities were considered simultaneously, childhood abuse and family instability were significantly associated with eversmoking for women, while all three adversities-low SES , childhood abuse , and family instability -remained statistically significant for men. --- Early-Life Adversities and Having a Smoking-Related Illness Early-life adversities continued to be significant predictors in the second stage, that is, having a smokingrelated illness . However, only some early-life adversities appeared statistically significant in the second stage. Specifically, the results from additive --- Early-Life Adversities, Life-Course Mediators, and Being a Recalcitrant Smoker For the third stage, we investigated early-life adversities and psychosocial factors that help us understand why some individuals with a smoking-related illness continue to smoke while others quit. For women, results from baseline models in Table 3 show that the risk of recalcitrant smoking is higher for women who grew up in low SES and unstable families . The unique effects of these two early-life adversities remained statistically significant even after all early-life adversities were estimated simultaneously in Model 1. There are five psychosocial factors that are significantly related to elevated risk of recalcitrant smoking for women at baseline: higher levels of education , higher levels of purpose in life , living with a partner , more financial strain , and mood disorder . In mediation analyses, we found that education has a significant indirect effect on the association between childhood SES and recalcitrant smoking for women by accounting for around 79% of the association . After controlling for education, the unique effect of childhood SES was no longer statistically significant . Regarding the unique effect of family instability on recalcitrant smoking, there are no life-course factors that show significant indirect effects . For men in Table 4, low SES in early life is associated with an increased risk of recalcitrant smoking in the baseline model. Yet, neither childhood abuse nor family instability had a significant effect on recalcitrant smoking. The results from baseline models showed that the risk of recalcitrant smoking for men is inversely associated with purpose in life , high family support , and living with a partner , yet the risk is positively associated with family problems . In the mediation analysis, we found that no life-course factors have significant indirect effects on the association between low childhood SES and recalcitrant smoking. In the final model, which includes all early-life adversities and psychosocial factors, we found that the effect of family instability remained significant and that there were two life-course factors-lower ) and not living with a partner were independent factors that explained why male smokers continued smoking despite having a smoking-related illness. In terms of the direct effect of early-life adversities in the final models, we found that gender differences were not statistically different. The indirect pathway from childhood SES to recalcitrant smoking through adult education was stronger for women than men even after accounting for all other potential mediators. --- Discussion Our study yielded three major findings. We found that individuals who experienced childhood adversities are more likely to be recalcitrant smokers in midlife. There are gendered patterns in the type of early-life adversities that uniquely shape the likelihood of being recalcitrant smokers. Based on prior research on childhood development [20], we expected that males' smoking behaviors would be more strongly affected by socioeconomic position in childhood. Indeed, we found an inverse association between childhood SES and the probability of being recalcitrant smokers, particularly for men. Theories of gender socialization and sex roles [29] further guide us that abusive and insecure relationships in early life might harm women more than men. We found that family instability is significantly associated with the increased risk of recalcitrant smoking for women but not for men. Prior research on substance abuse calls for more interventions that target those with childhood trauma [62]. Interventions that target women while addressing both substance abuse and complex trauma produce more favorable outcomes when compared to programs that only address substance abuse [63,64]. In a similar vein, smoking-cessation interventions for recalcitrant smokers who experienced early-life adversities might be more effective if the program provides coping skills for managing early-life trauma. More research is needed regarding whether gender-specific interventions would improve outcomes. Guided by cumulative inequality theory [33] and the life-course framework [34], we hypothesized that there are psychosocial factors that explain why some individuals continue to smoke despite having a smoking-related illness. We found that education in adulthood substantially explains why women who grew up in low-SES families are more likely to be recalcitrant smokers. However, even after accounting for all potential mediators, the direct effect of some early-life adversities remains significant. In particular, family instability is a robust predictor for women, while childhood SES is a robust predictor for men. For men, the mediating role of education in the association between childhood SES and recalcitrant smoking is negligible. None of the potential mediators substantially explain why women who grew up in unstable families tend to be recalcitrant smokers in later life. We interpret our findings in line with the biological embedding model, that is, early-life adversity induces significant developmental changes in children, modifying the maturation and responsiveness of physiological systems and developmental changes [65]. Early-life adversities may alter brain areas that govern executive functioning and reward systems [66], which may result in fostering impulsiveness and unhealthy coping behaviors, such as smoking [67]. Moreover, we cannot exclude the possibility that data limitations may affect the significance and strength of mediators given that all mediators were measured in midlife. Although we carefully selected the mediators based on the literature, we acknowledge the possibility that these mediators may not be unique to the early-life adversity. There may be other potential mediators that future researchers should consider. There are noteworthy life-course factors that independently explain why middle-aged individuals continue to smoke in the face of a smoking-related illness. For both genders, the risk of recalcitrant smoking is low for those who live with a partner. Our findings are in line with the literature on the positive aspects of marriage/cohabitation on smoking behaviors [68]. We also found gender-specific life-course factors. In line with research on the health benefits of education [69], education plays a role in recalcitrant smoking for women. Although it is established that smoking prevalence is higher among those with lower education [70], our findings expand prior work by indicating that education predicts a more harmful form of smoking, that is, smoking despite having serious medical conditions, particularly for women. We also found that the risk of recalcitrant smoking was higher when men have family members who struggle with their own health, substance use, finances, work, or marriage. These findings are in line with the principles of "linked lives" [20] and stress crossover [71]. That is, family members who suffer from their own problems may provide less support and more strain, which may inhibit men's smoking cessation. Like prior work [36,37], mood disorders matter for women's recalcitrant smoking, but the effect is not significant when an extensive set of mediators is taken into account. Several methodological limitations should be acknowledged. First, given that MIDUS lacks information on when respondents developed smoking-related conditions, we cannot establish the temporal order between the initiation of smoking and the development of a smoking-related illness. However, around 90% of eversmokers in MIDUS began regularly smoking before age 25 and most smoking-related conditions are likely to develop in later life. Thus, we assumed that, in the vast majority of cases, respondents would have begun smoking long before they developed a smoking-related illness. Second, indicators of early-life adversities are vulnerable to recall bias, and some indicators of earlylife adversities may not fully capture difficulties that individuals encounter in early life. For example, family instability is measured with a single indicator , so the diverse causes , duration, or severity of the adversity were not measured. Moreover, the measure of childhood abuse only includes emotional and physical abuse but not sexual abuse, which is more common among women [72]. Given the significant association between sexual abuse and smoking, particularly for women [11], this would lead to conservative estimates of the effect of childhood abuse. Third, we have created indexes-for example, family problems-by summing a wide array of indicators across different family members. Our findings, thus, do not provide more specific information relevant to smoking habits. Finally, although we have included potential variables that are carefully selected from the literature, we cannot rule out the possibility that there still remains confounding by unmeasured variables, a common limitation in observational research. In conclusion, using a longitudinal study of middleaged U.S. adults, we observed that disadvantaged environments and stressful experiences in early life might increase the risk of recalcitrant smoking. Moreover, the nature of early-life experiences may affect girls versus boys differently in terms of their risk of such a harmful smoking behavior. Future research should continue to examine how and why early-life adversities and potential mediators operate differently for men and women. To reduce the prevalence of such an intractable smoking habit, our results call for interventions for recalcitrant smokers who were disadvantaged in early life. --- Supplementary Material Supplementary material is available at Annals of Behavioral Medicine online. --- Authors' Statement of Conflict of Interest and Adherence to Ethical Standards The authors declare that they have no conflict of interest. Authors' Contributions C.L. led the conceptual and analytic design, analyzed the data, and drafted and revised the article. L.H. helped to formulate the initial idea, conducted preliminary analyses, drafted parts of the manuscript and contributed to the revision process. S.P. designed, conducted and drafted parts of the method section and contributed to the revision process. Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent Informed consent was obtained from all individual participants included in the study.

Background Little is known about life-course factors that explain why some individuals continue smoking despite having smoking-related diseases. Purpose We examined (a) the extent to which early-life adversities are associated with the risk of recalcitrant smoking, (b) psychosocial factors that mediate the association, and (c) gender differences in the associations. Methods Data were from 4,932 respondents (53% women) who participated in the first and follow-up waves of the Midlife Development in the U.S. National Survey. Early-life adversities include low socioeconomic status (SES), abuse, and family instability. Potential mediators include education, financial strain, purpose in life, mood disorder, family problems/support, and marital status. We used sequential logistic regression models to estimate the effect of early-life adversities on the risk of each of the three stages on the path to recalcitrant smoking (ever-smoking, smoking-related illness, and recalcitrant smoking). Results For women, low SES (odds ratio [OR] = 1.29; 1.06-1.55) and family instability (OR = 1.73; 1.14-2.62) are associated with an elevated risk of recalcitrant smoking. Education significantly reduces the effect of childhood SES, yet the effect of family instability remains significant even after accounting for life-course mediators. For men, the effect of low SES on recalcitrant smoking is robust (OR = 1.48; 1.10-2.00) even after controlling for potential mediators. There are noteworthy life-course factors that independently affect recalcitrant smoking: for both genders, not living with a partner; for women, education; and for men, family problems. Conclusions The findings can help shape intervention programs that address the underlying factors of recalcitrant smoking.

countries; primary among these factors is perceived racial discrimination . There have been three reviews of this expanding literature in the past 10 years , and all of them have reached similar conclusions: Discrimination is associated with worse mental and physical health. These reviews provide the background for the current study, which examines the relations between discrimination and physical health status versus health-impairing behavior . --- Discrimination and Physical Health The relation between discrimination and mental health is straightforward: Discrimination leads to an increase in negative affect, which can produce a decline in mental health. Selfreports of discrimination have been associated with elevated anxiety and depression , as well as anger and hostility . Pascoe and Richman's meta-analysis identified 105 studies that included measures of discrimination and mental health status. They produced a weighted average correlation of -.20 between discrimination and mental health outcomes. Almost all of these studies were cross-sectional; however, Schulz et al. found that increases in self-reported discrimination predicted increases in depression and decreases in perceived overall general health. Pascoe and Richman also identified 36 studies reporting a relation between discrimination and indicators of physical health . The average correlation in these studies was -.13. Although the correlations between discrimination and mental vs. physical health were not significantly different, Pascoe and Richman suggest that the relation with mental health may be somewhat stronger. Others have reached the same conclusion, pointing out that the effect of discrimination on physical health may be robust, but it takes longer for discrimination to produce physical health problems than either distress or hostility . The primary reason is that the former relation is mediated by the latter , and, therefore, may not appear in cross-sectional analyses . In fact, both the first and second paths of the discrimination → distress → health problems linkage have been shown repeatedly, but almost always in separate studies. --- Discrimination and Substance Use Discrimination also affects health status through its effects on health-impairing behaviors. Pascoe and Richman identified 13 studies that linked discrimination with unhealthy behaviors, such as substance use, and found an average correlation of .18. Several of these studies included prospective data. Gibbons et al. found that discrimination assessed at age 10/11 predicted substance use five years later in a panel of Black adolescents in the Family and Community Health Study . A similar relation between discrimination and problematic substance use was also found among the parents of these Black children. In fact, discrimination was the strongest predictor of problematic use of all of the factors that were assessed with the parents, including multiple types of stressors and contextual factors . In addition, analyses with both the parents and the adolescents found that the relation between discrimination and use was mediated by change in distress; in other words, discrimination at T1 predicted an increase in anxiety and depression from T1 to T2 , and this increase in distress was associated with an increase in self-reported use. --- Mediation of the Relations between Discrimination and Substance Use Anger vs. distress A subsequent series of studies with the FACHS sample, using both survey and experimental methods , suggested that the discrimination → use relation may be more complex than originally thought. When anger and hostility were added to the models as mediators, discrimination predicted changes in both distress and anger, as expected. However, the path from distress to use was no longer significant; in essence, it was replaced by the path from hostility to use. More specifically, for the parents, discrimination at T1 was associated with an increase in hostility at T2, and this change predicted an increase in problematic use three years later. The same pattern appeared with the adolescents: T1 discrimination was associated with elevated anger and distress, but only anger predicted use five years later; there was no effect of distress. --- Experimental evidence In a follow-up lab study , a subsample of the FACHS adolescents was asked to envision one of the following: a discriminatory experience, a stressful nondiscriminatory experience, or a neutral experience, and then their mood states and willingness to use drugs were assessed. Relative to the two nondiscriminatory scenarios, discrimination was associated with an elevation in both anger and depression, as well as drug willingness. However, anger, but not depression, was associated with drug willingness; consequently, only anger mediated the impact of discrimination on willingness. Similar results were reported by Stock, Gibbons, Peterson, and Gerrard who used the "Cyberball" paradigm as a way to manipulate perceived discrimination. In this case, Black young adults who thought they had been excluded by Whites in the Cyberball game reported more perceived discrimination and more willingness to use substances, and the relation between the two of them was mediated by anger . --- Differential Mediation: Internalizing vs. Externalizing Reactions There is precedent in the literature for the differential mediation hypothesis, i.e., anger / hostility is more strongly related to substance use, whereas distress is more strongly related to health problems, but the evidence is mostly indirect. First, distress is often associated with avoidance of risky behaviors . In contrast, anger / externalizing behavior has generally been associated with risk-taking , including substance use . Whitbeck et al. measured discrimination and affect among American Indian adolescents, and found that discrimination was associated with both internalizing and externalizing symptoms, but only the latter were related to substance use. Bardone et al. found that conduct disorder predicted health-risk behavior, including risky sex and alcohol and drug use, but not health problems. In contrast, anxiety predicted medical problems, but not substance use . --- Overview Most reviews of the discrimination / health literature have included a call for additional prospective studies of the relations among discrimination, negative affect, and health outcomes in order to determine why discrimination has pronounced effects on both physical and mental health. Literature reviews have also recommended examination of additional affective reactions as mediators of the relation between stress and physical health problems . The current research examined these relations in a panel of Black women across four waves of data, spanning eight years. Analyses examined cumulative discrimination as a predictor of both health status and health-impairing behavior , controlling for other types of stress . The following differential mediation hypothesis was made: Perceived discrimination is associated with increases in both physical health problems and problematic substance use; however, the former relation is mediated by change in internalizing reactions , whereas the latter relation is mediated by change in externalizing reactions . --- METHODS --- Sample FACHS is an ongoing study of psychosocial factors related to the mental and physical health of Black families. There were 889 families in the first wave , half from Iowa and half from Georgia. Each family had an adolescent who was in 5th grade at T1 and self-identified as African American or Black, and a primary caregiver . Most of the parents were the biological mothers of the adolescents. Because there were so few male primary caregivers, the current study focused only on the women; 680 of whom answered enough items across the four waves to be included in the analyses. Retention across the four waves was > 80%. The women had a mean age of 37 years at T1; 45 at T4. Their mean level of education was high school graduate. Approximately 65% of them were single mothers. --- Recruitment and Procedure Recruitment-Families were recruited from rural communities, suburbs, and small metropolitan areas, with mostly lower and middle class families, in Iowa and Georgia. Of those families contacted, 72% provided data . Median family income at T1 was $20,803/year ; 33% of the families were below the poverty line. For further description of the FACHS sample and recruitment, see Cutrona et al. ; Simons et al. . Procedure-All interviewers were African Americans who had received extensive training. Interviews lasted about 3 hours and required two visits. They included a computerassisted personal interview as well as a structured psychiatric diagnostic assessment . Participants received $100 at T1 to T3 and $125 at T4. Average time between waves was: T1-T2 = 22 months; T2-T3 and T3-T4 = 36 months. Informed Consent was obtained from all participants. The research was approved by the IRBs at each institution. --- Measures Time of assessment-Mediator variables were assessed at T1 and again at T3. Discrimination was measured at T2. The two health outcomes were assessed at T1 and then slightly different versions were assessed at T4. Covariates were all assessed at T1. Wave of measurement for each construct is noted below in parentheses. Perceived racial discrimination -Participants completed a 13-item, modified version of the Schedule of Racist Events . This measure, one of the most commonly used in the discrimination literature, describes various discriminatory events and asks how often respondents have experienced each type of event; e.g., "How often has someone said something insulting to you just because you are African American?" . Lifetime measures like these appear to be more effective than daily measures at predicting health problems . The 13 items were randomly parceled into three indicators of the latent construct. Distress -These items began: "During the past week, how much have you felt. "hopeless / depressed / discouraged / like a failure / worthless" for depression and "tense / uneasy / keyed up" for anxiety . Each item included a 3-point scale: 1 = not at all to 3 = extremely . The distress latent construct had these two indicators . --- Hostility (T1, T3 )-We used a definition of hostility, which is common in the health literature, that includes two components : behavior and affect . The UM-CIDI assessed seven types of anti-social behaviors , four of which pertained to physical violence and harming others . There were several questions for each type of behavior. If the participant endorsed one or more items for a behavior, she was considered to have engaged in that category. The total number of categories was summed, resulting in a score of 0 to 4. Anger was assessed with a single item: "You don't get upset too easily" from 1 = strongly agree, to 4 = strongly disagree. Thus, once again, there were two indicators; in this case, one for aggression and one for anger. Problematic alcohol use -Our focus was on problematic drinking. At T1 and T4, we used a question about amount of alcohol typically consumed at each sitting during the last year . We also used four questions from the UM-CIDI about experiencing problems due to alcohol use : fighting, problems at work, being arrested , and being harmed while under the influence . In addition, at T4, the interview included eight items regarding bad experiences in the past year due to alcohol use . Thus, for the problematic drinking latent construct, there were two indicators at T1 and three indicators at T4. Health status was assessed with two single items at T1 and T4, and a physical functioning scale assessed only at T4. The single-item measures were: a) current overall health status: "In general, would you say your health is?" from 1 = excellent to 5 = poor; which has been shown to be a good predictor of both morbidity and mortality ; and b) "Have you had a serious illness or injury in the past year?" . The scale comprised five items assessing the extent to which health status and/or pain interfered with physical functioning within the last 4 weeks; from 0 = No, not limited at all, to 2 = Yes, limited a lot . Covariates -Five variables were included as covariates because they have been linked with physical health status and substance use in previous studies: age, SES , negative life events , financial stress , neighborhood risk . Covariates and exogenous constructs were allowed to correlate, and the relations between all of the covariates and the endogenous constructs were estimated. --- RESULTS --- Descriptives Overall-More than 90% of the sample reported experiencing some discrimination; approximately 25% reported high amounts at each wave. Reports of alcohol problems were somewhat above the norm for women this age , more so at T4 than at T1 . The most common physical functioning problems were pain interfering with activities and limitation of activities due to health problems . Change over time-To examine change, repeated measures ANOVAs were conducted on the four outcome constructs that were assessed at T1 and then again at T4. Overall health status declined, whereas problematic drinking increased . The other two items, amount of alcohol typically consumed and serious injury / illness in the past year, did not change significantly . --- Overall Effect of T2 Discrimination Evidence of the effects of discrimination can be seen in the odds ratios involving T2 Discrimination and the T4 outcome measures. For these analyses, the outcome measures were dichotomized ; e.g., alcohol problems and functional disability present , overall health status . Controlling for the five covariates, the odds ratios were:Lifetime problematic alcohol use, OR = 1.88 ; Overall health status, OR = 1.55 ; Functional disability, OR = 1.50 . --- Structural Equation Model The primary analysis involved SEM-In the model, paths were specified from T2 discrimination through the T3 mediators , controlling for the T1 measures of each, to the T4 outcome measures of health status and problematic use, also controlling for their T1 measures. Measurement model-A confirmatory factor analysis was first conducted to test the fit of the measurement model. All constructs, except for covariates, were specified as latent variables, with the indicators mentioned above. The CFA provided a good fit to the data: χ 2 = 506.61; Comparative Fit Index = .94; Tucker-Lewis Index = .92; Root Mean Square Error of Approximation = .045. Several zeroorder correlations for the covariates and exogenous variables are worth noting. Four covariates were correlated with health problems at T4: rs ranged from .15 for negative life events, to .25 for financial stress . All five covariates were correlated with T4 problematic alcohol use . Correlations among the latent constructs can be seen in Table 1. Consistent with previous research, Discrimination was related to both distress and hostility at T3 . More important, and consistent with expectations, T3 Hostility correlated more highly with drinking problems than with health problems ; whereas the reverse was true for T3 distress: rs = .34 with health problems vs .19 with drinking problems; χ 2 [1] = 9.58, p = .002. Predicting change in distress and hostility-The structural model also fit the data well: χ 2 = 507.61, X 2 : df ratio = 2.22; CFI =.95, TLI = .92; RMSEA = .042 . Lagrange multipliers were used to detect any unspecified paths that could improve the fit of the model ; there were none. Stability paths for both Distress and Hostility were strong . In spite of the high stabilities, T2 Discrimination did have positive relations with change in both Distress and Hostility at T3: βs = .20 and .27, respectively . Predicting change in health problems and substance use-Together, the variables in the model explained 40% of the variance in T4 Health Problems and 59% of the variance in T4 Problematic Alcohol Use. These figures include the stabilities of the two outcomes, which were also very high over the eight year period . Nonetheless, Discrimination predicted change in both constructs, indirectly. First, for health status: T1-T3 Distress predicted Δ Health Problems ; and, as expected, Discrimination had a positive indirect relation with Δ Health Problems through Δ Distress: β = .04 . Regarding substance use: T1 to T3 Hostility had a direct positive relation with T4 problematic alcohol use, controlling for T1 Use: β = .20 . The anticipated indirect effect, in this case from T2 Discrimination through Δ Hostility to T4 Use, was also significant: β = .03 . Summary-Changes in distress were significantly associated with changes in physical health status, but not changes in problematic alcohol use; the opposite was true for changes in hostility. 1 Discrimination was associated with: a) increases in distress and hostility; b) a decline in physical health status, and that relation was indirect, through the increase in distress; and c) an increase in problematic alcohol use, and that relation was also indirect, through the relation between discrimination and hostility. --- DISCUSSION --- Discrimination and Negative Affect Prospective relations-As in previous studies , discriminatory experiences were associated with more distress and more hostility; this was the case at T2 / T3, and all other waves as well . These prospective relations maintained controlling for a number of covariates or confounders, each of which was also related to distress and/or hostility. Together with experimental evidence showing the same basic pattern in controlled laboratory settings , this suggests, as many have claimed or assumed in the past, that discriminatory experiences are responsible for increases in negative affect among Blacks. How that change in negative affect translates into health problems and health behaviors is a more interesting and more novel question also addressed by these data. Distress vs. hostility-The relation with discrimination was significant for both types of negative affect. In previous studies with younger FACHS participants, that relation was much stronger with hostility than with either anxiety or depression 2 . That was less the case with these Black women: Discrimination did correlate more highly with hostility than with distress, however, the relation with distress was fairly strong. This suggests that years of experience with discrimination may result in higher levels of depression , whereas the latter was not . 2 In previous experimental studies with young Black adults, self-reports of anger were higher than depression after envisioning a discriminatory experience and after being excluded by a group of White "players" in the Cyberball computer game . anger and hostility) in Black adults. Given its potential importance from both an etiological and intervention perspective, identifying factors that predict type of affective reaction to discrimination among Blacks and other minorities is worthy of future empirical attention. In this respect, these data support the contention of Lerner et al. that the relation between negative affect and health is both manifold and complex, and so is best understood by examining different kinds of emotional reactions separately. --- Discrimination and Health Behavior vs. Health Status Externalizing and substance use-The relations between distress vs. anger and change in problematic use adds to previous research showing that it is externalizing more than internalizing reactions to discrimination that link these aversive experiences with substance use problems. The increase in hostility fully mediated the association between cumulative discrimination and change in problematic alcohol use. This suggests that the change in problematic use was a reaction to the anger produced by the discriminatory experiences. In fact, many of the women who acknowledged substance problems also reported high amounts of both discrimination and hostility at T2. Moreover, previous research with the children of these FACHS women provided evidence that their substance use is reflective of a coping process: The discrimination → use relation was stronger for adolescents who endorsed the utility of substance use as a coping mechanism. Thus, substance use may reflect an effort by these women to mute the anger that comes from chronic exposure to discrimination. Physical health-Previous analyses have suggested that the nature of the discrimination / distress relation is as it was specified in the SEM: Perceived discrimination → distress, more than the inverse. What the current results add to that research is the prospective health component: reports of lifetime discrimination at T2 predicted change in distress, which then predicted change in health status three years later, controlling for negative life events, financial stress, and neighborhood risk, as well as age and SES--all of which predicted health problems by themselves. This prospective relation provides further evidence of the important effect that discrimination can have on the physical as well as the mental health of Black women. --- Future Directions Immunocompetence and cortisol-Several relations in these data appear to be worthy of further empirical attention. Because the discrimination measure assessed lifetime experiences, the fact that it predicted change in health status is consistent with the belief that it is the cumulative effect of discriminatory experiences that has the greatest impact on health . Presumably, this impact involves the immune systemexposure to discrimination over time, and the reactions it produces, can lead to reduced immunocompetence . This relation will be monitored in future waves of FACHS. Levels of cortisol secretion may also play a role in these relations. Internalizing after stressful events is associated with higher levels of cortisol ; and this tendency is exacerbated by rumination about the events . Elevated cortisol levels over an extended period of time increase the risk for a variety of health problems, including weight gain, diabetes, and cardiovascular disease . Finally, previous studies have also found associations between discrimination and diseases, such as coronary heart disease . That relation was not consistent in this data set ; however, the prevalence of CHD was low, most likely due to the age and gender of the sample. These relations among discrimination, rumination, and cortisol secretion are important and should be explored in future studies, both lab and survey. Substance use and physical health-Although their drinking was causing problems for some of these women, there is no clear evidence that this problematic use was having an effect on their physical health. In fact, the two were negatively correlated at T4, albeit weakly . Most likely, this will change over time for some of them-prolonged heavy use often leads to health problems -but at this age , it does not appear that the substance use was associated with any health problems, even for the women who experienced a lot of discrimination . One reason for this may be that alcohol and drugs mute negative affect , and they can also inhibit self-focused rumination , both of which can lead to health problems . The long-term relations among substance use and physical health will also be tracked in future waves of FACHS. --- Limitations Several limitations of the study need to be acknowledged. First, the sample included only Black women, mostly middle-aged, living in Iowa or Georgia. Black men or other minorities may respond differently than Black women to discrimination. In fact, there is some evidence that men are more likely than women to respond to anger and hostility with substance use, which suggests the discrimination / use relation may be stronger for Black men . Second, all of the data came from self-reports. Self-reports of substance use have been shown to be valid and reliable , and self-reported morbidity has been shown to be a better predictor of mortality than is physician diagnosis, especially among African Americans . Nevertheless, future studies should include both genders, as well as efforts to validate participants' responses to the kinds of measures used in this research. Third, the relation between distress and health status may be due partly to response style: those who report more negative affect are more likely to see their current health status in a negative light . The fact that both previous distress and health status were controlled mitigates this concern; still it must be considered. Fourth, the T3 Hostility and T4 Problematic Drinking constructs each contained a lifetime measure. Because the control for each was assessed at T1, there is the possibility that some of the change detected in the T3 hostility construct actually occurred before discrimination was assessed, and/or that some of the change in T4 problematic drinking occurred before T3 hostility was assessed. Thus, although the discrimination → anger → use relation has been shown in several previous studies , there is some uncertainty with regard to the temporal ordering of those constructs in these analyses. Finally, because the T1 and T4 outcome measures were not identical, we cannot draw any conclusions about absolute changes in health status, other than the fact that overall perceived health status declined significantly. It is also worth noting that problematic drinking increased significantly . This is not surprising, given that it was a lifetime measure. However, the amount of increase is unusual during this period of life. More important, this increase in problematic drinking was strongly related to discrimination. --- 3 --- Conclusion Perceived racial discrimination is associated with increases in internalizing and externalizing reactions among Black women. However, these two reactions appear to have different health consequences. Increases in internalizing are associated with deterioration in physical health status, including limits on functioning and increases in general morbidity. Increases in externalizing are related to more substance use problems. Together, these relations affect overall mental and physical health and, in so doing, may contribute to the relative disparity in health status experienced by African Americans in the U.S. --- Correlations among Latent Constructs

Objective-Prospective data tested a "differential mediation" hypothesis: The relations (found in previous research) between perceived racial discrimination and physical health status versus health-impairing behavior (problematic substance use) are mediated by two different types of affective reactions, internalizing and externalizing. Methods-The sample included 680 African American women from the Family and Community Health Study (M age = 37 at Time 1; 45 at Time 4). Four waves of data were analyzed. Perceived discrimination was assessed, along with anxiety and depression (internalizing) and hostility / anger (externalizing) as mediators, and physical health status and problematic substance use (drinking) as outcomes. Results-Structural equation modeling indicated that discrimination predicted increases in both externalizing and internalizing reactions. These affective responses, in turn, predicted subsequent problematic substance use and physical health status, respectively, also controlling for earlier reports. In each case, the indirect effects from discrimination through the affective mediator to the specific health outcome were significant and consistent with the differential mediation hypothesis.externalizing reactions among Black women, but these reactions are related to different health outcomes. Changes in internalizing are associated with self-reported changes in physical health status, whereas changes in externalizing are associated with changes in substance use problems. Discussion focuses on the processes whereby discrimination affects health behavior and physical health status.

Introduction Young people's early sexual encounters are primary markers of the transition to adulthood because "they occur at the time of marriage or because they bring with them opportunities for further emotional and relational development as well as the possibilities of marriage and/or parenthood" . However, it is widely recognized that early initiation of sexual activity predisposes adolescents to negative sexual and reproductive health outcomes, such as unwanted pregnancies and sexually transmitted diseases. Indeed, desire to understand the determinants of early sexual activity among young people, the HIV/AIDS pandemic, and the need for evidence-based interventions to delay coital activity have led to an extensive pool of literature on adolescent sexual behavior both in the developed and developing world. Abstinence, one of the three facets of HIV prevention efforts relying on the ABC approach, has been a point of controversy. Indeed, the efficacy and practicality of abstinence promotion efforts in the US have been called into question . Engaging in the debate surrounding the promotion of sexual abstinence among adolescents is not our aim as the issues are well-documented; rather, we examine early sexual initiation in a context where HIV infection, early pregnancies and associated impacts on schooling, and other negative sexual and reproductive health outcomes remain constant threats to the wellbeing of young people . In addition, the youth upon which this paper is based are situated in a context where sexuality education continues to be highly contested, with parents and school systems reluctant to introduce such education, teachers inadequately prepared to deliver it, a large number of children out of school, and a political climate largely averse to the very notion of young people as sexual beings. --- Theoretical Framework We examine predictors of first sexual activity among adolescents living in slum and nonslum settlements in Nairobi, Kenya through the theoretical lens of the protection-risk conceptual framework . The conceptual framework describes the relations of protective factors and risk factors to involvement in problem behaviors such as drug use, alcohol abuse, delinquency, and early sexual intercourse experience . Briefly, the model posits that protective factors lower the probability of engaging in problem behaviors by providing: models for conventional behavior, controls against problem behaviors, and an environment that supports conventional behavior. Protective factors may also mitigate the effect of exposure to risk factors . Risk factors, on the other hand, increase the probability of problem behaviors by providing models for and opportunities to engage in deviant behaviors, as well as increasing personal vulnerability. We acknowledge that sexual behavior in itself is not a problem behavior; nonetheless, the primary focus of the study is precocious sexual initiation, which we view as potentially qualifying as a problem behavior. It is problematic in the slum context because it largely occurs much earlier than among other population sub-groups and in a context where HIV prevalence is almost three times the national prevalence . The fact that younger adolescents are less likely to have adequate knowledge on how to protect themselves against unwanted pregnancy and STIs or about how to handle interpersonal relationships that include sex is evident from the very high HIV prevalence rates among adolescents in Africa: in a region that accounts for almost 70% of all cases of HIV/AIDS in the world, approximately half of all new infections occur among young people aged 15 to 24. Further, we would argue that the prevailing culturally-supported abstinence message for young people creates a general perception of sexual activity in this age group as deviation from 'acceptable' behavior. Although the conceptual framework adopted in this paper was developed in the United States, it has been successfully applied in several countries and within different cultures . Jessor and colleagues , in a cross-national study employing this conceptual framework to examine adolescent involvement in problem behaviors , observed that while Chinese and American adolescents differed on descriptive and theoretical measures, the models of association were similar in both countries. In both samples, the model accounted for 45% of the variation in problem behavior involvement. Addition of marijuana use and sexual activity to the problem behavior measure in the US sample increased the proportion of variance accounted for by the model to 51%. A more recent study by Vazsonyi and colleagues in Georgia and Switzerland also observed cross-national generality in the application of the model. Vazsonyi and colleagues tested the application of the model in explaining adolescent engagement in alcohol and drug use as well as other deviant behavior, such as theft and vandalism. Although the authors considered sexual behavior as a problem behavior, it was not included in the models because sexual behavior data were not collected in Georgia for religious reasons. While the application of theoretical frameworks developed in one context to a different setting has been questioned, Jessor , in a recent editorial, challenges scholarly overemphasis on the influence of cultural differences on theoretical explanations. In his words, sensitivity to cultural differences stems, in part, from "our awareness of entire disciplines, such as anthropology, that have long taught us about the uniqueness of different cultures and societies and that have brought their sometimes exotic practices to our attention" . Indeed, Jessor contends that while we may observe differences in theoretical constructs across cultures or nationalities, the relations between these constructs should remain unchanged. Bearing in mind Jessor's argument and given the successful application of the model in various settings, we apply it in this Kenyan context, but remain cognizant of the importance of local realities. --- Limitations of Previous Studies A review of the existing literature highlights several shortcomings of many of the studies that investigate adolescent sexuality. First, most studies in sub-Saharan Africa utilize crosssectional data which simply examine relationships between sexual debut and other variables. Longitudinal data would help us move towards addressing causal linkages since we can control for timing of various events and covariates that precede sexual debut. Second, data from the commonly used Demographic and Health Surveys and other demographic surveys do not contain adequate information to allow examination of the effect of psychosocial protective and risk factors on sexual behavior. Third, analyses using DHS data to address differences between slum and non-slum areas require use of a proxy measure of slums since DHS data do not distinguish slums from non-slums. This paper uses data from the actual slum and non-slum geographic locations. Lastly, many sexual and reproductive health studies focus primarily on females and cover only those aged 15-19 and often do not include very young adolescents . However, recent evidence shows that significant numbers of very young adolescents in sub-Saharan Africa are sexually active and yet they lack sufficient knowledge about sexual and reproductive health. --- Objectives The aims of this study are twofold. First, we seek to identify predictors of first sexual activity among adolescents in slum and non-slum neighborhoods in Nairobi. Second, we assess whether protective and risk factors at the individual and social levels have comparable levels of effectiveness for older versus younger adolescents, as well as for adolescents living in slum settlements and those living in poor, but non-slum neighborhoods. High-risk urban neighborhoods may form a unique context which poses challenges for the sexual and reproductive health of young people. Nairobi's slum settlements, for example, are characterized by poor sanitation and housing, congestion, a lack of basic infrastructure such as roads, inadequate public services such as water, education and health. Furthermore, widespread unemployment, violence, and insecurity are the norm within these settings . Evidence from studies conducted in Nairobi's slums indicates that the median age at first intercourse is much lower in these slum settings and that slum dwellers fare much worse in terms of risky sexual behavior when compared to their wealthier urban counterparts or those living in rural areas . Indeed, Zulu and colleagues observed a 5 year difference in age at first sex between those who grew up in the slums and those who grew up in other parts of the city. Further, even after controlling for religion, age, and schooling, women who grew up in slums were significantly more likely to have initiated sexual intercourse at a younger age and to report multiple sexual partners. It is plausible that programs designed for more advantaged neighborhoods may flounder when confronted with the vast neighborhood disadvantage that slums represent. Roche and colleagues found, for instance, that in socio-economically disadvantaged U.S. neighborhoods, parental rules were associated with a lower likelihood of sex initiation. However, in more advantaged neighborhoods, parental rules were positively associated with sex initiation. There is a general need for information about factors that trigger or lead to first sexual activity in disadvantaged African settings. Knowledge of the effects of parental monitoring and peer models are an important initial step to developing recommendations for young people and parents in Africa's urban slum contexts. This study draws on longitudinal data collected in 2005 and a year later under a larger study designed to explore various schooling-related issues, including the association between school participation and risky behaviors. The longitudinal nature of this study allows us to examine the relationship between transition to first sex during the twowave interval and antecedent sociodemographic and risk and protective factors measured during the first wave of data collection among a sample of adolescents aged 12-19 years. We hypothesize that adolescents who transition into first sex between the two waves will be older, more likely to live in slum versus non-slum areas, and to be out of school. We also postulate that those who report fewer friends who engage in conventional behavior, lower levels of parental monitoring, and a greater proportion of friends who engage in unconventional or risky behavior will be more likely to make the transition. --- Methods --- Study Design, Participants and Procedures The data used in this study are drawn from two waves of the Education Research Program , a longitudinal population-based study in two slum and two non-slum settlements in Nairobi, Kenya. The study is nested in the Nairobi Urban Health and Demographic Surveillance System , which collects routine health and demographic data from over 60,000 individuals living in more than 21,000 households in two slum areas in the city . The ERP has been following children aged 5-19 years in these two slum communities as well as in two other non-slum communities since 2005. Jericho is a low income area while Harambee is a lower middle income area; however, most of the inhabitants in both communities are employed in the formal sector . Data are collected using five modular questionnaires that address specific issues: 1) the household module identifies individual households to which children belong, household members and household characteristics; 2) the primary school module collects information on school characteristics; 3) the parent or guardian module asks about parental involvement in school activities and in the child's life, as well as parental perceptions of the Kenyan free primary education initiative that was introduced in 2003; 4) the child module assesses each child's schooling status and experiences, informal training and apprenticeship, as well as general behavior ; and lastly, 5) the child schooling module collects information on each child's enrollment in school and schooling history. Each of the sections is regularly updated with the child schooling module being updated every term , while the other modules are updated annually . The behavior section of the child module is completed by respondents aged at least 12 years and the section must be completed with the child as the respondent. This paper primarily uses data collected using the child module, which includes measures of perceived levels of parental monitoring, perceived peer behaviors, and self-reported substance use and sexual behavior. At the first wave, 284 females and 303 males reported that they had ever had sex . Nine percent and 8.3% of females and males, respectively, who were virgins at Wave 1, had transitioned into first sex by Wave 2. The mean age of respondents at Wave 1 was 15.0 years for males and 14.9 years for females. Over 70% of the respondents were living in one of the two slum settlements. Over 80% of males and females were enrolled in school during Wave 1. --- Measures Outcome variable-At both waves of data collection, respondents were asked whether they had ever had sex. Three groups of adolescents are defined: virgins -those that reported in both waves that they had never had sexual intercourse, transition -those that experienced first sex between the two waves, and non-virgins -those that reported that they had ever had sex at Wave 1. Demographic and psychosocial characteristics of all three groups are summarized in Table 1. The primary outcome variable for the analyses is whether a respondent transitioned into first sex between Waves 1 and 2 . --- Explanatory variables Social context protective factors-The measures of social context protective factors are parental monitoring and peer models for conventional or pro-social behavior . Perceived parental monitoring is measured using 9 items that assess the respondents' perception of how much their parents or guardians know about the following: where the child spends time on weekday evenings; with whom the child spends weekday evenings; where the child spends time on weekend evenings; with whom the child spends weekend evenings; what the child does during his/her free time; how the child spends his/her money; what TV programs, videos, or films the child watches; what books, novels, or magazines the child reads; and the child's best friend. Possible responses are never know , sometimes know , usually know , or not applicable. "Not applicable" responses were treated as missing values. About 1% of adolescents had missing values on three or more items. Scores on the scale were summed up to give an index score ranging from 0 to 18 with higher values reflecting greater perceived parental monitoring. Cronbach's alpha was used to assess internal consistency of scores, a measure of the extent to which related items on a scale are correlated and assesses whether these items produce similar scores . Cronbach's alpha values range from 0 to 1 with increasing values indicating greater consistency of item scores. The Cronbach's alpha for scores on the parental monitoring scale was 0.88. Peer models for conventional or pro-social behavior was measured using four items: the proportion of friends who: get good marks in school, participate in sports or other school activities, attend church/mosque, and want to go to secondary school, university, or college . Possible responses are none of them , some of them , most of them , don't know, or not applicable. "Don't know" and "Not applicable" responses were treated as missing values. Social Context Risk Factors-A composite measure of peer models for unconventional behavior was used to assess risk factors at the perceived social context level. This measure of models risk was based on a 5-item measure of perceived peer involvement in unconventional behavior, that is, how many friends: drink alcohol, run away from home, have gotten into trouble with police, have had sex, and use drugs like marijuana , khat , or glue. Possible responses are none of them, some of them, or most of them . Individual Level Risk Factors-Risk factors at the individual level included general deviance, non-penetrative sexual contact , and substance use. General deviance was measured through 7 items that assess the number of times the respondent had engaged in the following activities in the 4 months preceding the survey: stayed away from home without parental permission; started a fight; stolen or tried to steal something; carried a weapon for protection; hit or threatened to hit an adult; delivered or sold drugs; and delivered or sold alcohol. Possible responses are never , once , 2 or 3 times , 4 or 5 times , 6 or more times , or refused. Refusals were treated as missing values. Less than two percent of adolescents refused to respond to these questions and were treated as missing values. Scores on the scale are summed up to give an index score ranging from 0 to 28 . Non-penetrative sexual contact and substance use were measured as dichotomous variables . Sociodemographic Characteristics-We also examined the association between transition into first sex between Wave 1 and Wave 2 and several sociodemographic characteristics -age at Wave 1, schooling status at Wave 1 , slum versus non-slum residence, and number of adolescents in the household . Separate analyses for slum and non-slum residence did not show any significant differences between study sites . Thus, the models shown here do not include study site as a predictor variable. Information on ethnicity was lacking for non-slum residents, who are not part of the NUHDSS. Preliminary analysis using data from respondents in the slum areas showed that ethnicity was not significantly associated with transition into first sex. Thus, we do not control for ethnicity in the models reported here. Statistical Analyses-Data were analyzed using Stata version 9.2 . Univariate statistics were computed to describe the respondents' psychosocial, behavioral and sociodemographic characteristics, as well as sexual experience. Two thousand, three hundred and twenty four adolescents completed the behavior section of the education child module in both waves. One hundred ninety respondents retracted their initial report of ever having had sex and were excluded from analyses. The final sample size is therefore limited to the 2,134 adolescents with consistent sexual behavior data in both waves. Of these respondents, 1,358 were categorized as virgins , 189 made the transition to first sex while 587 were non-virgins at Wave 1 . Two hundred seventy nine respondents who reported first sex at Wave 2 but gave an age at sexual debut that was younger than age at Wave 1 were recoded as non-virgins. Logistic regression models were employed to identify correlates of transition to first sex among the subset of adolescents who reported that they had never had sexual intercourse at the time the baseline survey was conducted . Baseline measures were used to predict transition into first sex. At the multivariate level, data were analyzed separately for males and females. We run three sets of logistic models: separate models for younger versus older adolescents; separate models for slum versus non-slum residence; and models including interactions terms for age group and slum residence. Ensuing findings should be interpreted in light of several limitations. First, the duration between the two waves of data collection is about a year and since the actual month of first intercourse is unknown, it is not possible to investigate the effect of these predictors on the actual timing of first sexual intercourse within that interval. Second, there are only two waves of data. Having information on the actual timing of first intercourse over multiple waves of data collection would enable us to better understand and explain the process of making the transition to first sex. Lastly, the available data has relatively few measures of risk and protective factors that could influence initiation of sexual activity. --- Results --- Descriptive Analyses Among females who made the transition to first sex, the median age at first intercourse was 18 years for those living in non-slum areas and 15 years for those living in slum areas. On the other hand, among males the median age at first intercourse was 17 years for those living in non-slum areas and 15 years for their counterparts residing in the slums. Table 1 summarizes the demographic, psychosocial, and behavioral characteristics of the adolescents at Wave 1 according to their sexual behavior status. Non-virgins were significantly older than both the virgins and those who transitioned into first sex. Adolescents who transitioned into first sex between the two waves were on average older than those who remained virgins. The three groups did not differ on the proportion living in slum versus non-slum areas. Non-virgins at Wave 1 were more likely to be out of school. Among females, a significantly lower proportion of those making the transition to first sex were enrolled in school at Wave 1 compared to virgins. Virgin and transition females did not differ in terms of peer models for conventional behavior and reported levels of parental monitoring; however, non-virgin females reported significantly lower levels of peer models for conventional behavior and perceived parental monitoring than either group. Males who transitioned into first sex reported lower levels of peer models for conventional behavior and lower levels of parental monitoring than their virgin counterparts. Females who transitioned into first sexual activity reported more peer models for unconventional or risk behavior than their virgin counterparts. While males who made the transition to first sex reported more peer models for unconventional behavior than their virgin counterparts, the difference in means was only marginally significant. Virgins and those who transitioned into first sex did not differ on deviant behavior; however, nonvirgin respondents were significantly more likely than either group to report other delinquent behavior. Slum and non-slum dwellers differed on several protective and risk factors . Both males and females living in non-slum areas reported significantly more peer models for conventional behavior than their peers in the slums. Females in the slums reported higher levels of parental monitoring but lower levels of peer models for unconventional behavior than their non-slum peers. A greater proportion of females living outside the slums reported non-penetrative sexual contact and substance use than their counterparts in the slums. Both males and females living outside of slums reported lower levels of delinquent behavior than slum residents. --- Multivariate analysis Results from the logistic models are presented in Tables 345. Table 3 shows the results of the models by age group and sex. The results of the models by area of residence and sex are presented in Table 4; and models including interactions terms for age group and slum residence are showed in Table 5. Six categorical variables and four continuous variables were used in the models. For the categorical variables, the odds ratio represents the chances of making transition to first sex for the specified category in comparison with the reference category. For the continuous variables, the odds ratio indicates the odds of transitioning into first sex for each unit increase in the corresponding variable. Odds ratios greater than 1 indicate a greater likelihood of making the transition to first sex while odds ratios lower than 1 indicate lower chances of making the transition to first sex. Two-tailed pvalues are presented in the tables. For females aged 12-15 years, only perceived parental monitoring and delinquent behavior had a significant effect on the chances of becoming sexually active . Among girls in this age group, for each additional unit increase of parental monitoring and delinquent behavior, the chances of transitioning to first sex increases by 10% and 40% respectively. For girls aged 16-19 only peer models for unconventional behavior was found to significantly influence the chances of having first sex. Specifically, for each additional unit increase in the index assessing peer models for unconventional behavior, the chances of becoming sexually active increases by 80%. For 12-15 year old males, only residence was significantly associated with transition to first sex. Slum residents were 10 times more likely to become sexually active than their counterparts living in non-slum areas. Similarly for males aged 16-19 only residence had a significant effect on the odds of losing virginity with those living in non-slums being 3.3 times more likely than their counterparts in slum areas to have transited to first sex. In the second set of logistic models for separate analyses by area of residence , age group is significantly associated with transition to first sex among males and females living in non-slum areas and females in slum areas. As expected, older adolescents were significantly more likely to have made the transition to first sex. Among females living in non-slum areas, parental monitoring, and peer models for unconventional behavior also predicted transition into first sex. Among their male counterparts, no other variables besides age group were significantly associated with transition to first sex. For females and males living in slums, peer models for conventional behavior and delinquent behavior were associated with transition to first sex. For both females and males, there was a significant interaction between age group and slum residence . Among females, young girls living in non-slum areas were significantly less likely to make the transition to first sex than females aged 16-19 years living in slums. Wald tests to examine differences between coefficients for the interaction terms showed that 12-15 year old females living in non-slum areas were also less likely to make the transition to first sex than 16-19 year olds living in nonslum areas. Among males, 12-15 year olds living in non-slum areas were significantly less likely to make the transition to sexual activity than males aged 16-19 years living in slums. However, compared to males aged 16-19 years living in slums, males in the same age group living in non-slum areas were significantly more likely to make the transition to first sex. There was no statistically significant difference between younger and older males living in slums. Wald tests to examine differences between coefficients for the interaction terms showed that 12-15 year old males living in non-slum areas were less likely to make the transition to first sex than 12-15 year olds living in slum areas and 16-19 year olds living in non-slum areas. In summary, age and slum residence were found to significantly predict transition to first sex. In general, older age and slum residence were associated with greater odds of making the transition to first sex. Among females living outside slums, school attendance was associated with lower odds of making the transition to first sex than being out of school. A high level of parental monitoring was associated with greater odds of making the transition among females living in non-slum areas and among younger females. Having peer models for conventional behavior was negatively associated with the likelihood of transitioning to first sex for males and females living in slum areas. On the other hand, peer models for unconventional behavior were a risk factor for girls aged 16-19 and females living in nonslum areas. --- Discussion This paper uses longitudinal data to examine predictors of transition to first sex among adolescents aged 12-19 years in slum and non-slum areas of Nairobi, Kenya. It focuses on the association between transition to first sex and sociodemographic characteristics, as well as risk and protective factors measured during the first wave of data collection. The study provides a unique perspective of transitions to first sex by comparing the experiences of adolescents living in both slum and non-slum areas. Unlike previous studies on sexual behavior in slum settings , this paper examines the association between transition into first sex and psychosocial variables such as perceived levels of parental monitoring, peer models for conventional or pro-social behaviors, and peer models for unconventional or antisocial behaviors. Consistent with previous research showing that slum dwellers fare much worse in terms of risky sexual behavior than their peers living outside slums, we observe that adolescents living in the slum areas initiate sexual activity about three years earlier than their non-slum counterparts. Between the two waves of data collection, younger adolescents aged 12-15 years living in slum areas were significantly more likely than their non-slum counterparts to make the transition into first sex. Yet, slum dwellers do not necessarily fare worse in terms of the presence or absence of protective and risk factors as defined herein. Understanding attributes of the social context of urban slums that facilitate precocious sexual initiation may be essential for effective programs aimed at mitigating early sexual initiation in slum communities. Dodoo and colleagues , for instance, have noted that cramped living conditions in urban slums limit privacy as parents are often forced to share sleeping space with children, thus exposing children to sexual activity early on in life. Further, exposure to parental sexual activity may weaken adult control over their children's sexual behavior. Space constraints may also force young people to move out of parental homes to their own dwellings prematurely, providing them with opportunities to engage in risk behavior away from parental watch. Interestingly, we observe that for males aged 16-19 years, those living in slums were less likely to make the transition to first sex than their counterparts living in non-slum areas. How do the circumstances differ for this group? This study found that the median age at first sex was 15 among males living in slum areas compared to 17 years among their counterparts living in non-slum areas. We posit that males living in slums who, despite all odds, remain virgins beyond the typical age of first intercourse in the slums may be more likely to be resilient to pressures to engage in sexual intercourse. Indeed, for adolescent males living in slum communities, peer models for conventional behavior significantly reduce their likelihood on making the transition to first sex. Among girls living outside slum areas, being in school was associated with a lower likelihood of making the transition to first sex compared to being out-of school. Previous studies among 12-19 year old Kenyan adolescents , 14-22 year old South African youth , and among 15-24 year old Ivorian youth have also found school enrolment to be associated with a lower likelihood of sexual activity. As in other studies, the impact of schooling on sexual behavior appears stronger for girls than for boys. We are unable to ascertain whether sexual and reproductive health education is provided in the schools represented in our sample. Knowledge of whether a school has sex education would have provided insight into whether being in a school that offers sex education delays initiation of sexual activity. As noted by Kaufman and colleagues , the impact of education on sexual behavior may differ significantly for boys and girls. The stronger effect of schooling on sexual behavior among girls in nonslum areas compared to boys may also reflect the possibility of greater dropout among girls due to pregnancy meaning that sexually experienced girls are under-represented in school samples. However, Mensch and colleagues argue that pregnancy is unlikely to be the primary reason for disruption of schooling for young girls because the same factors that lead to dropouts also lead to early childbearing. Given the potential success of schools in protecting girls, there is clearly a need for more school-based research and gender analysis in order to understand the dynamics therein and to determine how the possible benefits derived by girls from the school setting can be extended to boys as well. Having peer models for conventional behaviors, such as friends who perform well in school, who desire to advance their education, and who participate in pro-social activities such as sports or religious activities, was associated with a lower likelihood of transitioning into first sex for males and females living in slums. In addition, for females aged 16-19 and females living in non-slum areas, increasing numbers of friends engaging in delinquent behaviors was associated with increased chances of making the transition to first sex by Wave 2. As boys and girls make the transition from childhood to adolescence, identification with peer groups becomes critical. Peers, therefore, serve as important models of appropriate behavior and also influence the extent to which young people engage in risk activities, including risky sexual behavior . Our findings are consistent with previous studies showing peers' behaviors and attitudes to be associated with adolescent sexual behavior . However, we are cautious to assert that peers necessarily influence adolescent sexual behavior and acknowledge that adolescents may choose friends who share similar qualities and values as themselves. High parental monitoring at Wave 1 was associated with greater odds of transitioning into first sex by Wave 2 for females aged 12-15 years and females living in non-slum areas. This is contrary to expectations that high parental monitoring would deter young people from engaging in risk behaviors, such as precocious sexual activity. However, it is consistent with some of the literature. High parental monitoring could derive from parents' perception that a child is more likely to engage in risk behavior. Furthermore, high parental monitoring may be perceived by young women as unwarranted or overzealous strictness, which could in turn lead to actions that symbolize their own autonomy. Rodgers for example, in a study among school going adolescents in the United States, found that sexually active females who perceived their parents as being psychologically controlling were more likely to engage in high risk sexual behavior than those who perceived their parents as being less controlling. Given that first sexual intercourse is not always desired and rates of coerced sexual activity are reportedly higher in urban slums due to widespread violence and insecurity in these settings, the results of this analysis are insightful. A population-based survey conducted in Kibera slum in Nairobi, for instance, found that 43% of girls and 15% of boys aged 10-19 years reported that they were coerced into their first sex . Within this context, understanding factors that may predispose young boys and girls to early sexual activity is important for efforts to reduce high STD and HIV prevalence among adolescents in sub-Saharan Africa. Our findings underscore the importance of considering the social and environmental contexts when examining pathways to first sexual intercourse among adolescents. We argue that there is need to focus on very young adolescents, particularly those growing up in resource poor settings, or those who are out of school, as these young people may be more likely to make the transition to first sex and hence, be more vulnerable to negative health outcomes stemming from precocious sexual activity. The paper also highlights the need to strengthen parents' capacity to adapt their parenting strategies to the needs of their changing/ evolving adolescents.

While early sexual experiences are a key marker of the transition from childhood to adulthood, it is widely acknowledged that precocious initiation of sexual activity predisposes adolescents to negative health and psychological outcomes. Extant studies investigating adolescent sexuality in sub-Saharan Africa often rely on cross-sectional data lacking information on the socialpsychological underpinnings of adolescent behavior. Through the theoretical lens of the protection-risk conceptual framework, this paper draws on two waves of longitudinal data collected from 2,134 adolescents to examine sociodemographic, psychosocial and behavioral predictors of transition to first sex among adolescents living in slum and non-slum settlements in urban Kenya. We employ logistic regression models to examine the effect of antecedent sociodemographic and risk and protective factors measured during the first wave of data collection on transition to first sex by the second wave. We observe that transition to first sex is influenced by age, slum residence, perceived parental monitoring, and peer behavior. We also find evidence for coupling of risk behaviors. Study findings underscore the need to focus on very young adolescents and those growing up in resource poor settings as these young people may be highly vulnerable to negative health outcomes stemming from precocious sexual activity.

Narrow focus on drugs and tests Chief among these is the push for development of "novel" antimicrobials. For example, the latest report from the Independent Review on Antimicrobial Resistance, chaired by Jim O'Neill, emphasised the need for de-linking drugs' profitability from sales volumes. 4 5 This builds on other recent work, such as that by the think tank on international affairs Chatham House, which has outlined alternative business models to similarly change the current financial models for encouraging and supporting research and development in new antibiotics. 6 Meanwhile, in practice, in the United States there has been an extension to marketing exclusivity, accelerated review, and a relaxation of requirements for approval by the Food and Drug Administration. 7 Although this leniency may have increased the development and launch of new antibiotics, there is worrying evidence that such "fast tracking" may generate considerable adverse effects. 8 Critical, of course, is the basic fact that because resistance to an antimicrobial begins as soon as it is developed, new agents can never be the sole solution-and certainly not necessarily the most cost effective or sustainable. Mechanisms to promote the sustainable use of antimicrobials are also needed, but work has increasingly focused on rapid diagnostic tests to support the more "appropriate use" of antimicrobials. This was a key topic in the previous report from O'Neill's review. 9 Research Councils UK is also supporting diagnostics development, 10 and the influential Longitude Prize is to be awarded to whoever first develops a specific rapid diagnostic tool. But even if such tests are developed they can only ever be a partial solution, and their value will be negated by systemic factors, such as out-of-pocket payments increasing the risk of a course of antimicrobials not being completed, and relative costs making it more likely that antimicrobials would be used without the test, as antimicrobials are often very cheap. These and other factors all point to sustainable antimicrobial use requiring considerable behavioural, cultural, political, and economic change rather than just use of a diagnostic test to identify whether an infection is viral or bacterial or whether it is a sensitive or resistant infection. --- New vision needed This is not to suggest that social aspects are being ignored. However, trends in activity, in the balance of funding between basic and social science, and in political and popular opinion indicate that the vision for tackling antimicrobial resistance is Provenance and peer review: Not commissioned, not externally peer reviewed. thebmj.com Feature: Speeding new antibiotics to market-a fake fix?

Antimicrobial resistance has reasserted itself on the national and international agenda as a critical threat to public health and health systems. It undermines the very foundations of modern healthcare, from joint replacements to chemotherapy, threatens to reverse the decline in mortality and morbidity from infectious diseases, jeopardises animal health and welfare, and poses potentially crippling financial effects. 1 2 It is intrinsically a biological phenomenon, which has, perhaps naturally, led to much of the discussion on tackling it being driven from a biological, and broader scientific, perspective. However, the conditions promoting, or militating against, the biological mechanisms of antimicrobial resistance are deeply social, shaped by cultural, political, and economic processes. Such social aspects include: • The ways farmers, vets, and regulatory systems manage livestock production for human consumption • How regulatory and fiscal frameworks incentivise or deter antimicrobial development, production, and use • How the public and healthcare professionals understand, value, and use antimicrobials • The context in which animals and humans interact, and • The ways in which particular groups of people are exposed to particular microbial infections. 3 Actions to reduce and control antimicrobial resistance will therefore involve change in social practices, but at present the discourse and, critically, the investment of time, money, and intellectual capital are heavily biased towards technological solutions.

THE BENEFITS OF POSITIVE SOLITUDE IN LATE LIFE Chair: Yuval Palgi Co-Chair: Ehud Bodner Discussant: Dikla Segel-Karpas Positive solitude is the capacity to choose spending time by yourself in a positive manner. This session provides a wide glance on the advantage of this capacity at the second half of life. The session will try to present new theoretical perspectives regarding this capacity. The lectures will give an opportunity to follow the directions in which research in this new field is being developed. The first lecture by Palgi will describe the theoretical background for the study of positive solitude, and will provide new findings from the positive solitude scale that was lately develop by the authors. The second presentation by Bodner will describe how emotional regulation through music moderates the relationship between mindfulness and positive solitude. The third lecture by Zambrano Garza is contributing to the understanding of solitude in the interpersonal domain. Based on dyadic diary study, demonstrates that more voluntary solitude was associated with more positive affect of the partner and more negative solitude was related to more negative affect of partner. The forth lecture by Segel-Karpas will focus on the contribution of positive solitude and loneliness on negative aspects of mental health. Finally, the fifth presentation, by Jennifer Lay, will show use natural language processing to identify solitude experiences from older adults' reports. We will conclude the session by discussing future research directives for the implementation of positive solitude in the field of gerontology, such as the development of interventions that may enhance the tendency for positive solitude in old age.

Virtual Reality (VR) has become increasingly accessible for older adults, providing opportunities for interventions that address loneliness and social isolation in long-term care. However, the effectiveness of VR programs can be influenced by various factors, such as the backgrounds, preferences, and capacities of the target population. This qualitative study investigates the acceptability and feasibility of a recreational VR program for social engagement in two Canadian long-term care homes since January 2023. The study involved 20 residents (with various levels of cognitive and physical impairments) who participated in weekly VR group sessions facilitated by staff. Ethnographic observation and video-recorded conversational interviews were conducted with residents during the VR sessions. We also conducted 10 focus groups with 20 staff members. Four patient partners were involved as co-researchers in the team. We performed the thematic analysis with patient partners. We identified three themes: (1) storytelling builds residents' sense of self, (2) positive emotions persist even when the video is forgotten, and (3) VR empowers resident-resident and staff-resident connections. The findings demonstrate that using VR in long-term care settings is feasible and acceptable for older adults with different cognitive and physical impairments. VR programs have the potential to enhance social engagement and support residents' personhood as a meaningful activity by improving inclusion, social engagement, comfort, and recognition of their identity. Future research could explore the long-term impact of VR experiences in addressing social isolation and loneliness among older adults in long-term care.

Introduction Prolonged or complicated bereavement has long been a controversial category in the field of Psychiatry. A turning point in the recognition of the category has been the inclusion of persisting complicated bereavement disorder as a provisional category in DSM5 and the adoption of prolonged grief disorder in the forthcoming ICD-11 . These developments make it timely to examine the relationship of complicated bereavement and posttraumatic stress disorder , disorders that are both triggered by traumatic losses. We investigate the pattern of overlap of the two constellations by applying latent class analysis to data from a sample of West Papuan refugees displaced by mass conflict and persecution to neighboring Papua New Guinea . Events such as atrocities, extrajudicial executions, and other forms of politically motivated killings commonly expose refugees to traumatic loss and personal threat , experiences that are known to trigger both PTSD and complicated bereavement. Further, amongst refugees from collectivist cultures, disruptions to family and kinship groups, eviction from ancestral lands and displacement to foreign and deprived environments, may accentuate symptoms of identity confusion and alienation that are intrinsic to both PTSD and complicated bereavement . We anticipated, therefore, that amongst West Papuan refugees, identity confusion would be prominent amongst symptoms of a combined pattern of complicated bereavement and PTSD. The ADAPT model offers a framework for examining the mental health impact of conditions of insecurity, disrupted interpersonal bonds, and undermining of the sense of identity amongst refugees. The model identifies five support systems eroded by mass conflict and displacement, including safety and security; interpersonal bonds and networks; justice; roles and identities; and existential meaning . Two of these systems are recognized as central to mental health in the National Institute of Mental Health Research Domain Criteria framework . Consistent with the RDoC, the ADAPT model attempts to bridge the divide between a descriptive or nomothetic approach to identifying mental health problems , and an idiographic framework in which personal development and collective experiences shape and give meaning to subsequent psychological reaction patterns. The ADAPT model, therefore, provides a framework for a transdiagnostic approach in which overlapping symptoms of PTSD and complicated bereavement may represent a meaningful response to concurrent exposure to complex ecological and social experiences such as mortal threat, traumatic loss, and disruptions to identities and roles . Although several studies have investigated the relationship between PTSD and complicated bereavement in high-income countries , there is a dearth of parallel research into the topic conducted amongst refugee populations. Although complicated bereavement was largely distinguishable from PTSD in a study amongst Bosnian refugees, the two constellations overlapped in relation to the domain of intrusive memories . In a sample of Mandaean refugees in Australia, LCA identified a comorbid complicated bereavement and PTSD class in addition to pure complicated bereavement and PTSD classes, respectively . Although suggestive of the importance of a combined complicated bereavement and PTSD class amongst refugees, the data did not clarify the psychosocial factors that may be specific to that pattern. The long history of persecution that West Papuan refugees have experienced has exposed many members of the community to traumatic loss, mortal threat, disruptions to identities, and a sense of belonging . Since the invasion and annexation of the territory by Indonesia over 50 years ago, the occupying military has committed widespread atrocities, including torture, disappearances, extra-judicial imprisonment, and mass displacement of communities, in an attempt to suppress the low-grade armed resistance war waged by indigenous groups seeking national independence for the territory . Successive waves of West Papuan refugees have crossed the border into neighboring PNG, the largest concentration resettling in Kiunga, a remote town near the border with the homeland. The community in Kiunga lives in constant fear of incursions by hostile elements from across the nearby border. In addition, they face multiple deprivations relating to geographical isolation, harsh living conditions including food and water shortages arising from floods and drought, and lack of employment opportunities and services. The absence of mental health services in the region means that West Papuan refugees have not been exposed to international concepts of trauma, PTSD or complicated bereavement. The aims of our study were to identify a subpopulation of refugees with a combined constellation of complicated bereavement and PTSD and to assess whether that pattern is associated with a specific profile of past and ongoing adversities. Using LCA, we tested the following hypotheses: in this cross-cultural setting, it would be possible to identify subpopulations with relatively independent clusters of PTSD and complicated bereavement, respectively, thereby supporting contemporary international classification systems; in addition, there would be a class manifesting combined symptoms of complicated bereavement and PTSD; the latter class would be characterized by prominent symptoms of identity confusion and alienation; and a distinctive pattern of traumatic events, post-migration living difficulties, and background psychosocial disruptions would characterize the complicated bereavement-PTSD class. --- Method Full details of the methodology are provided in online Supplementary Material 1. --- Sample Between March and September 2016, a full household survey was undertaken of all adult West Papuans living in the nine villages where the community is concentrated in Kiunga. We included persons originating from West Papua or born to at least one West Papuan parent. The analytic sample comprised all those with whom we made contact , noting that 18.3% of the community were traveling in other parts of PNG during the entire course of the study. --- Ethics Ethical permission for the study was provided by the University of New South Wales Human Research Ethics Committee and the Medical Research Council of PNG Ethics Committee. --- Measures The Refugee Mental Health Assessment Package is a comprehensive tool assessing psychosocial factors and common mental disorders amongst refugees . Details of the qualitative and psychometric steps taken to develop, adapt and test the mental health measure in a study amongst West Papuan refugees have been provided previously . --- Symptoms of complicated bereavement and PTSD Details of the qualitative methods used to adapt the symptom measures to the culture are provided in online Supplementary Material 1. These steps included the development and testing of modules to assess complicated bereavement and PTSD symptoms using items consistent with both DSM5 and ICD-11 criteria. --- Trauma and stressors Based on our qualitative inquiries, we identified five items representing traumatic loss, each scored 1, if present. We adapted the Humanitarian Emergency Settings Perceived Needs Scale --- Procedure Interviews were conducted by a field team in Bahasa Indonesian, English, and Tok Pisin . The field interviewers were drawn from the West Papuan community and the team was managed by a West Papuan refugee . The team received 3 weeks' intensive training from a clinical psychologist followed by 3 months of piloting the interview in the field. --- Statistical analysis We applied LCA to data from the whole sample to identify subpopulations of West Papuans manifesting differential patterns of complicated bereavement and PTSD . We applied the Bayesian Information Criterion , sample size-adjusted Bayesian Information Criterion , and the Akaike's Information Criterion to assess the fit of serial models . In addition, we applied the Vuong-Lo-Mendell-Rubin and the Lo-Mendell-Rubin adjusted likelihood ratio tests to compare successive models . We applied the principle of parsimony, the degree of class separation, homogeneity of posterior probabilities within classes, and the interpretability of the classes to assist in deciding on the final model . We ranked conditional probabilities according to recommended criteria as high , moderate or low . We applied multinomial logistic regression to compare the classes with the traumatic event and PMLD counts, and the ASI dimensions. Collinearity required that we tested the three predictors in separate regression models. Analyses were performed in STATA version 13 and Mplus Version 7. --- Results --- Sociodemographic characteristics The sample included 486 adults , the mean age being 35.8 years. Half the sample had completed primary school education , and 9.5% held post-school degrees or certificates. Over half originated from West Papua, the remainder being offspring of West Papuan parents. The West Papuan born had lived in Kiunga for a mean of 15.6 years. The majority of the sample had indeterminate status as displaced persons, 14.6% were PNG citizens, and 2.8% held permissive residency status which conferred the right to remain in PNG with some restrictions. A quarter reported one or more loss in the past 12 months and a third experienced a traumatic event , thereby meeting DSM-5 entry criteria for either PCBD or PTSD or both. Tables 1 and2 detail exposure to loss and traumatic events as well as PMLDs. The mean score for exposure to PMLDs was 1.82 . --- Latent class analysis LCA supported a four-class solution . Specifically, model fit indicators improved up to and including the four-class model, but only marginal gains were achieved by increasing the number of classes beyond that point. The decision to adopt the four-class solution was supported further by the VLMR and the LMR adjusted likelihood ratio tests which showed no statistical changes when progressing from a four to five class model. Given these findings and the interpretability of the classes, we adopted the four-class model. The four classes comprised a complicated bereavement class , a posttraumatic bereavement class including items of complicated bereavement and PTSD , a PTSD class , and a low-symptom class . Table 4 shows the posterior probabilities for symptoms of complicated bereavement and PTSD in relation to each class. In the complicated bereavement class , eight complicated bereavement symptoms exhibited high endorsements by over half of the sample and the remaining 10 items received moderate endorsement . Items in the high probability range included core bereavement characteristics of yearning, preoccupations with the deceased, and intense feelings of sorrow and emotional pain. In contrast, all symptoms of PTSD in this class fell into the lower level of moderate or low probability range. In the combined posttraumatic bereavement class , comprising 10% of the sample, respondents rated most items of complicated bereavement and PTSD in the high probability range. Specifically, for complicated bereavement, probabilities for 15 out of 18 symptoms exceeded 0.60 and the remaining three fell between 0.59 and 0.15 ; and for PTSD, 16 of 20 symptoms exceeded probabilities of 0.60 and the remaining four fell between 0.59 and 0.15. For complicated bereavement, high probability items included core features of preoccupations and persistent yearnings but also extended to maladaptive appraisals, bitterness/anger, interpersonal problems and emotional numbness. The high probability items for PTSD in this class included flashbacks, intrusive thoughts, internal and external avoidance, and anhedonia. Symptoms falling into the moderate range included, for complicated bereavement, feelings of confusion, emptiness, and a diminished sense of identity ; and for PTSD, concentration difficulties, insomnia, startle response and hypervigilance. In the PTSD class , seven items fell into the high range including intrusive memories, psychological reactivity, avoidance, anhedonia, detachment, irritability, and posttraumatic amnesia, and the majority fell into the moderate probability range of >0.59 and <0.15. In this class, virtually all complicated bereavement symptoms fell into the low probability range. In the low symptom class , comprising two thirds of the sample, most symptoms of both complicated bereavement and PTSD yielded low probabilities. --- Multinomial logistic regressions Table 5 presents the findings of the three multinomial logistic regression models. The four-class LCA structure represented the No statistically significant effects were evident for sociodemographic factors in any of the three regression analyses. The only significant predictor for the complicated bereavement class was the ASI domain of disrupted interpersonal bonds and networks . In contrast, the combined posttraumatic bereavement class was associated with higher exposure to traumatic loss events , PMLDs and greater disruptions in the ASI domains of interpersonal bonds and networks and roles and identities . The PTSD class reported higher exposure to traumatic loss events and was unique in its association with the ASI pillar of safety and security . In common with the posttraumatic bereavement class, the PTSD class reported greater disruptions in the ASI domain of roles and identity . --- Discussion LCA yielded a four-class solution comprising three morbid classes and a low symptom class, the latter accounting for over two-thirds of the sample. The three morbid classes, each representing roughly one-tenth of the sample, comprised a complicated bereavement class, a combined posttraumatic bereavement class, and a PTSD class. Notably, the posttraumatic bereavement class was characterized by a distinctive combination of symptoms related to identity confusion and alienation. Members of the posttraumatic bereavement class reported high levels of adversity reflected in traumatic losses, post-migration living difficulties and disruptions to two of the ADAPT psychosocial support domains of interpersonal bonds and networks and identity and roles. In support of conventional international classification systems, separate classes emerged for complicated bereavement and PTSD, respectively. In keeping with theory, the ASI domain of disruptions to bonds and networks was associated with the complicated bereavement class, whereas erosion of safety and security was related uniquely to the PTSD class. The PTSD class also reported disruptions in roles and identities and exposure to high levels of traumatic loss. Prior to discussing our findings, we consider the strengths and limitations of the study. We applied a rigorous sampling approach, identifying West Papuans according to the triangulation of census data and a whole-of-household survey. We achieved a high response rate even when absentees from the catchment were accounted for. Although Kiunga is the largest settlement of West Papuans in PNG, restriction of sampling to one location limits the generalizability of our findings. The study is cross-sectional, cautioning against drawing causal inferences from the analyses undertaken. Memory biases could result in either over-or underreporting of past traumatic events. In addition, exposure to trauma may increase the tendency to report mental health symptoms. There is also a risk of transcultural error in measurement when undertaking studies of this type. To limit the risk, we followed a systematic mixed methods approach to develop and adapt our measures to the culture and context. Our qualitative inquiries suggested that the key mental health constructs of PTSD and complicated bereavement were well recognized by West Papuan refugees even though the population lacked familiarity with international terminology for classifying these reactions. Specifically, West Papuans recognized all the ICD and DSM symptoms of complicated bereavement, applying a specific term in Bahasa Indonesian to describe the syndrome in their culture. To avoid excessive complexity, we did not include other diagnostic categories such as depression which could be salient in generating symptoms of identity confusion and alienation. Because of restrictions in the sizes of the respective latent classes, we could only compare each morbid class with the no/low symptom class in our logistic regression analyses. In addition, in applying multinomial regression analysis, collinearity amongst our three predictors required that we assess the impact of traumatic loss events, PMLDs, and the ASI domains separately. Caveats notwithstanding, our findings offer support for our key hypotheses. Conventional classes of complicated bereavement and PTSD emerged from the LCA. The ASI domain of disrupted bonds and attachments was associated with the complicated bereavement class as would be anticipated. Notably, the PTSD class reported high levels of exposure to traumatic losses, consistent with the criteria of international classification systems . In addition, the PTSD class reported greater erosion of the identity and role domain of the ADAPT model, supporting the importance of identity disturbance as an integral component of the PTSD reaction . The key finding was that 10% of the sample exhibited the combined posttraumatic bereavement pattern. Importantly, the characteristics that were accentuated in this class extended beyond core PTSD and complicated bereavement symptoms to those that fall broadly under the domain of identity confusion and alienation, including maladaptive appraisals , bitterness/anger, interpersonal problems, emotional numbness, feelings of confusion and emptiness, and a diminished sense of identity. It is notable that most of these symptoms were identified spontaneously by West Papuans participating in the preliminary focus groups. There are compelling reasons why West Papuans would highlight symptoms of identity confusion and alienation. The society --- Psychological Medicine is grounded in an agrarian, collectivist culture in which personal identity is strongly bound up with ties to the family, kinship group, and traditional lands. The longstanding campaign of repression pursued by the occupying military has led to major disruptions to this traditional way of life. Mass immigration into West Papua from other parts of Indonesia has added to the sense of threat to the national identity of the indigenous people . In addition, the group participating in our study comprised a population displaced to a remote town across the border where they experienced ongoing deprivations, fear, and a sense of marginalization. Overall, the history of persecution appeared to be mirrored by the pattern of symptoms of grief, fear, and alienation represented by the symptoms of the posttraumatic bereavement class. It also is notable that there is a correspondence between the identified symptoms of identity confusion and alienation within the posttraumatic bereavement class and elements of complex traumatic stress disorder described amongst survivors of human rights violations and abuses in the western literature . Our findings build to efforts to bridge the gap between idiographic and nomothetic models of understanding of traumatic stress by demonstrating the connection between ecological factors, in this instance, politically motivated psychosocial disruptions, trauma and ongoing stressors, and a distinctive pattern of combined PTSD and complicated bereavement observed at the individual level. This approach helps to counter the tendency to regard mental health symptoms as solely serving the function of signifying the presence of pre-defined categories of mental disorder . Our findings have important clinical implications. Although there is some evidence in support of the efficacy of cognitive behavioral interventions in treating complicated bereavement in nonrefugee populations , no culturally adapted interventions of this type have been systematically trialled amongst refugees . Given that 20% of participants had heightened symptoms of complicated grief , there is a pressing need to develop and test appropriate therapies for this reaction pattern amongst refugees. In addition, our findings challenge the prevailing tendency to focus on single diagnoses in the refugee field by demonstrating the relevance of comorbid presentations which may require more comprehensive psychological interventions . Specifically, in addition to the focus on issues of safety and traumatic loss, refugees with the posttraumatic bereavement pattern may require special attention to issues of identity confusion and alienation. Failure to focus on the latter issue may account in part for low levels of success reported in some studies treating socially isolated and alienated refugees with complex symptom presentations . There may be value, therefore, in formulating and trialing a specific approach to psychological intervention that focuses on elements of both complicated bereavement and PTSD for refugees that show the combined pattern. --- Conclusions We identified a combined class comprising complicated bereavement and PTSD amongst refugees, in which symptoms of identity confusion were prominent. That class reported a distinctive profile of exposure to past trauma, postmigration stressors, and psychosocial disruptions. More generally, the study illustrates the value of investigating connections between comorbid patterns of mental health symptoms and distinctive profiles of trauma, postmigration stressors and longer-term psychosocial disruptions that refugees have experienced. Defining these relationships may assist in shaping and refining psychotherapeutic interventions to meet the specific needs of subpopulations of refugees. Supplementary material. The supplementary material for this article can be found at https://doi.org/10.1017/S0033291718002027.

Background. Refugees are at risk of experiencing a combined constellation of complicated bereavement and posttraumatic stress disorder (PTSD) symptoms following exposure to complex traumas associated with personal threat and loss. Features of identity confusion are central to both complicated bereavement and PTSD and these characteristics may be particularly prominent amongst refugees from traditional cultures displaced from their homelands, families, and kinship groups. We investigate whether a combined pattern of complicated bereavement and PTSD can be identified amongst West Papuan refugees participating in an epidemiological survey (n = 486, response rate: 85.8%) in a remote town in Papua New Guinea. Methods. Latent class analysis was applied to derive subpopulations of refugees based on symptoms of complicated bereavement and PTSD. Associations were examined between classes and traumatic loss events, post-migration living difficulties (PMLDs), and psychosocial support systems. Results. The four classes identified comprised a complicated bereavement class (11%), a combined posttraumatic bereavement class (10%), a PTSD class (11%), and a low symptom class (67%). Symptoms of identity confusion were prominent in the posttraumatic bereavement class. Compared with the low symptom class, the combined posttraumatic bereavement class reported greater exposure to traumatic loss events (OR 2.43, 95% CI 1.11-5.34), PMLDs (OR 2.24, 95% CI 1.01-4.6), disruptions to interpersonal bonds and networks (OR 3.3,, and erosion of roles and identities (OR 2.18,. Conclusions. Refugees appear to manifest a combined pattern of complicated bereavement and PTSD symptoms in which identity confusion is a prominent feature. This response appears to reflect the combined impact of high levels of exposure to traumatic losses, PMLDs, and disruption of relevant psychosocial systems.

Introduction There is increasing evidence that non-medical opioid use has spread beyond urban areas in the US [1][2][3][4]. While the modal route of administration for non-medical opioid use varies geographically [5], for those who develop a serious drug abuse disorder, intravenous injection is common. This transition increases risk of blood-borne viral infections, most especially HIV and the hepatidites , and opioid overdose [6][7][8][9]. Since harm reduction services such as syringe exchange programs have been implemented in urban areas. Exposure to these services among nonurbandwelling people who inject drugs is likely to be negligible. Nevertheless, because many nonurban injectors report going to urban locales to buy and/or inject drugs, we hypothesised that this might result in exposure to harm reduction programs with resultant increases in prevention knowledge and reductions in unsafe injection practices that result in blood-borne infection or overdose. The association between knowledge about a given health threat, risk behaviour and disease state has been well established and is supported by theoretical models [10][11][12][13][14]. Most recent research that specifically examined HIV knowledge in the US has focused on populations such as immigrants residing in the US [15]. PWID residing in nonurban areas are insufficiently studied, both in terms of their knowledge and degree of risky behaviour. Recent U.S. studies suggest that hepatitis knowledge levels are lower than those for HIV [16][17][18][19][20]. HCV infection is often perceived as a harsh inevitability, particularly relative to risk of HIV infection [19,21,22], and a realistic one for PWID in the US where prevalence rates range from 31 to 95% depending upon when and where the data were collected [19,[23][24][25][26]. Most PWID are infected with HCV within the first two years of initiating injection drug use [27,28]. Recent declines in both HCV incidence and prevalence [28][29][30] notwithstanding, there is continued concern about increased HCV risk in nonurban locales [31][32][33]. Several national and international studies have sought to describe injection-associated risk behaviours particularly with respect to HCV infection [23,[34][35][36][37][38] where HCV incidence is increasing among nonurban young PWID in the US [33]. There are conflicting reports concerning the association between awareness of HIV or HCV infection and injectionassociated risk behaviour, some studies noting no association [24,39,40] and another finding a tendency to reduce risk behaviours when individuals are aware of their infection [41]. Contextual factors such as relationship status, withdrawal symptoms [42], lack of access to harm reduction services [30], and drug type [43] were associated with increased injectionassociated risk behaviours. Given the lack of recent information regarding knowledge about risk behaviours associated with, and seroprevalence of injection-associated infections among PWID residing in nonurban locales, we recruited and enrolled PWID residing in the nonurban towns of Fairfield and New Haven Counties in southwestern Connecticut. Of the 51 towns and cities in the two counties, six have populations ranging from approximately 80 to 144 thousand inhabitants. The remainder have considerably less with over two-thirds having populations less than 30 thousand and are considered nonurban municipalities located within proximity to larger Northeast cities . We compared individuals who injected drugs most often in urban locales to those who injected drug most often in nonurban locales and tested four hypotheses: --- 1. PWID who inject most often in urban locales will have lower income, less job stability, higher rates of incarceration, longer injection careers and larger injection networks; --- 2. they will be more knowledgeable about HIV, viral hepatitis and opioid overdose risk and prevention; --- 3. they will have lower levels of unsafe injection practices, greater use of existing harm reduction services, and lower rates of opioid overdoses; and 4. they will have higher seroprevalence rates for HIV, HBV and HCV and lower rates of recent opioid overdose. --- Methods The Suburban Health, Education, Research, and Prevention Alliance study was a mixed methods, longitudinal study of adult PWID stably residing nonurban towns in Fairfield or New Haven Counties of Connecticut. We were interested in understanding the potential influence of most frequent injection venue upon injectionassociated risk behaviours, knowledge about HIV, hepatitis, and overdose risk and prevention, and HIV, HBV and HCV seroprevalence. Hence, all participants resided in nonurban locales , but varied in terms of the locale where they most often injected in the previous six months. Our four hypotheses were based on the notion that primary injection venue will influence individuals' exposure to and adoption of harm reduction strategies. The current report is limited to analyses from the final baseline dataset. More information concerning study methods can be found in previous publications [44,45]. All participants provided informed consent prior to enrolling in the study and received up to $60 for completion of the baseline assessment. The Yale Human Investigations Committee reviewed and approved the study and all associated materials. --- --- Measures Participants completed a two-part semi-structured baseline interview. The first part, conducted by trained staff, was a face-to-face interview to collect geospatial data more easily obtained through open-ended discussion and the use of maps. Participants then completed the second part using audio computer-assisted self-interview software . After completing both parts of the interview, a trained phlebotomist obtained a 4-6 ml blood sample from participants and instructed them to return for their test results in two weeks. Independent variables included: most frequent injection locale in the past six months, sociodemographics, health and substance abuse treatment history, social support, use of harm reduction services and involvement with the criminal justice system. Minority representation was low but commensurate with the towns' demographics. The race/ ethnicity variable was therefore dichotomised . Participants completed six clinical measures, including those items from the Addiction Severity Index [48][49][50] that are needed to calculate the seven subscales, three consumption questions from the Alcohol Use Disorders Identification Test [51,52], Brief Pain Inventory [53,54], Center for Epidemiological Studies Depression Scale [55], and Beck Anxiety Inventory [56,57]. The outcomes of interest for the four hypotheses included: injection venue; HIV, hepatitis and overdose knowledge; injection-associated risk behaviours; and HIV, HBV and HCV infection status. The knowledge variable was calculated as the percent of correct responses to 42 True/False items concerning HIV and hepatitis transmission and prevention and overdose recognition and response that we have used in previous studies [17,58,59]. To reduce the potential for type I error due to multiple comparisons, a dichotomous composite injection-associated risk behaviours variable was calculated based on participants' reports of having engaged in at least one of the six risk behaviours during the 30 days . Sera were prepared and stored at -20°C, subsequently thawed, and tested using serological test kits . HBV testing included screening for core and surface antibodies and for surface antigen. Participants received their results in a face-to-face post-test counselling session; if positive for antibodies to HIV, HBV surface antigen or HCV, they were referred for confirmatory testing at a certified laboratory where they could then be referred for treatment if the confirmatory test was also positive. Study staff counselled participants on strategies to prevent viral transmission, and those who were negative for all three HBV tests were informed that they were susceptible to infection and advised to receive the three-dose vaccination series. --- Statistical Analysis We initially tested for potential differences between the 438 participants who responded to the item concerning most frequent injection locale and those who did not; no differences were noted for sex, race, education or employment status, involvement with the criminal justice system, or any of the six risk behaviours assessed. Non-responders were significantly more likely to be married. To address the first hypothesis, we calculated chi-square and Student's t-tests to assess for potential differences in characteristics between participants who reported having injected most often during the previous six months in nonurban vs. urban locales. To address the remaining three hypotheses, primary injection locale was included as an independent variable when testing the three outcomes of interest . Initially, we conducted a series of bivariate logistic analyses to assess the relationship between primary injection venue, the other independent variables, and the outcomes of interest of knowledge, injection-associated risk behaviours and viral infection status. A series of bivariate linear regression analyses were similarly conducted to determine the association between primary injection venue, other independent variables, and knowledge level. Variables with a P >0.25 in the bivariate analyses were excluded from the three multivariable analyses; injection venue was included in all models as the primary independent variable of interest. A backward selection procedure was used to sequentially eliminate covariates that did not remain significant. The significance level for inclusion in the multivariable models was defined as P <0.05 . All statistical analyses were performed using SAS . --- Results A detailed description of the study sample is available in previous publications [44,45]. Briefly, the majority of participants was non-Hispanic White and male. The race/ethnicity proportions were: White 83.7%; Hispanic 8.7%; African American 6.3%; Other 1.3%; one participant refused the question . In testing whether PWID who injected predominantly in urban areas differed on sociodemographic factors from their nonurban counterpart , we found few differences between the two groups save that those injecting most often in urban locales were younger by almost six years , had been injecting nearly three years less , and were less likely to have health insurance , Regardless of location, most had been in substance abuse treatment at least once and had a criminal record. Almost all participants reported having been arrested at least once, 80.0% of whom reported incarceration periods longer than that necessary to post bail . The mean total number of arrests was 9.1 and 3.1 were for drug violations; the mean number of incarcerations extending beyond the time necessary to post bail was 5.7 . No between-group differences were noted for gender, race, education, employment status, monthly income, or the size of participants' injection networks for the past six months. Knowledge level for the total sample was poor, no one answered all 42 items correctly, and the overall mean score was 59.5% . The hypothesis that PWID injecting in urban locales would have greater knowledge about HIV/AIDS, hepatitis, and opioid overdose was not supported in bivariate or multivariable analyses. More knowledgeable participants were significantly more likely to be White , have at least a high school education , and have had at least six injection partners in the past six months . With respect to injection-associated practices , 90.5% of participants identified heroin as their preferred drug, 64.9% reported having purchased drugs most often in urban areas in the past six months, while 22.8% relied upon home delivery. Regardless of where participants purchased their drugs, 62.4% reported that they injected most often in their own home . Within the previous 30 days, most PWID purchased syringes at pharmacies, 3.7% reported receiving most of their syringes from either of the two existing syringe exchange programs, and 7.8%) reported receiving any syringes from a syringe exchange program. On average, participants injected slightly more often than twice per day and frequently re-used their own syringes. When asked about six injectionassociated behaviours, nearly half the sample reported having engaged in at least one during the previous 30 days. The most commonly reported risk was sharing drug , although sharing of drug-mixing or rinse water was also common. Almost a third reported having ever experienced an overdose, and among these individuals, it was common to have experienced more than one. Based on the assumption that PWID who injected most often in urban locales were more likely to have been exposed to harm reduction programs than were those who injected most often in nonurban locales, we hypothesised that the former group would be less likely to engage in at least one of the six injection-associated risk behaviours and would experience fewer non-fatal opioid overdoses. Neither group had much exposure to harm reduction programs, and our hypotheses regarding injection-associated risk behaviours and overdose experience were not supported. In the multivariable model , those who injected most often in urban settings were almost twice as likely to engage in at least one injection-associated risk behaviour as their nonurban counterpart . Older participants and males were less likely to engage in injectionassociated risk behaviours . We hypothesised that HIV, HBV and HCV seroprevalence would be significantly higher among those who injected most often in urban locales. Seroprevalences for the total sample were: 23.6% for HBV, 39.2% for HCV and 1.1% for HIV. There were too few cases of HIV to perform any inferential test, and bivariate associations of injection locale with either HBV or HCV infection were non-significant. --- Discussion This report presents the primary analyses from the Suburban Health, Education, Research, and Prevention Alliance project: a comparison of knowledge levels, injection-associated risk behaviours, and the prevalence of HIV, HBV and HCV infection between PWID residing in nonurban areas of southwestern Connecticut who primarily injected in urban locales and those who did not. To our knowledge, this is the largest longitudinal study of active injectors from a nonurban region of the US. We tested four hypotheses, none of which were supported by the data, suggesting that nonurban PWID-regardless of primary injection venue-are not being reached by existing syringe exchange or harm reduction programs. This may possibly be attributed to insufficient opportunities for nonurban PWID to come into contact with such programs due to limited hours of operation or geographic coverage. Or it may be due to a lack of awareness of the existence of such programs among nonurban PWID, limited advertising by the programs in urban areas and none in nonurban regions, the existing harm reduction interventions may be poorly suited to the information and resource needs of this population or other as yet unidentified factors. Additional research is needed to understand how best to effectively reach and intervene with PWID residing in nonurban locales. The findings raise two concerns: prevention knowledge and exposure to harm reduction services and resources is low; and injection-associated risk behaviours were highly prevalent. There are only two official harm reduction programs in the region, both are located in major urban areas, have limited hours, and access to these services via public transportation is not possible from all areas or may require up to 45 minutes to reach by private car. Innovative strategies are therefore needed to disseminate harm reduction information and resources to this population. Pharmacies may represent one such novel venue for expanding nonurban harm reduction efforts beyond merely selling syringes [60]. Although there is a 1992 law permitting syringe sales without the need for a prescription in Connecticut [61,62], implementation of harm reduction interventions such as training PWID about injection hygiene or overdose prevention and response remain relatively scarce in nonurban locales. Smartphone technology such as text-based programs that provide regular messages concerning methods to improve injection hygiene, strategies for coping with cravings, and information about access to local harm reduction and substance abuse treatment programs may be another strategy for implementing interventions targeting nonurban PWID. Expansion of home delivery of syringes and other safe injection supplies beyond the large cities where most harm reduction programs operate is strongly recommended and essential in preventing further spread of HCV which is already at 40%. At the structural level, policy changes aimed at counteracting the prevailing "NIMBY" attitudes [63][64][65][66] and increasing the number of substance abuse treatment and syringe exchange programs located in nonurban locales are recommended. In Connecticut, syringe exchange programs are limited to operating only in the jurisdictions within which they have been approved. Changing the policy to permit home delivery to a larger region may be another approach to expanding access. We also recommend that the existing exchanges be converted to distribution centres where the number of syringes distributed is based upon need rather than a strict one-for-one exchange as is currently the case. HIV, hepatitis and overdose recognition and prevention knowledge was higher within larger injection networks and suggests that there may be diffusion of health promotion information within these networks. This may, in turn, provide another possible intervention strategy [67,68]. The fact that, contrary to our hypothesis, those injecting most often in urban locales were significantly more likely to have engaged in at least one injection-associated risk behaviour within the previous month suggests that these individuals may have been injecting in a hurry or in a location not conducive to hygienic injection . The issue that women reported engaging in injection-associated risk behaviours more often than men was not surprising albeit disappointing. Many factors have been attributed to this phenomenon including inherent power dynamics between genders [69][70][71][72], suggesting the need for harm reduction interventions tailored to the specific needs of female injectors. --- Limitations There are several limitations to this study. The sample is one of convenience, and therefore the findings may have limited generalisability. PWID with higher incomes may be underrepresented. The self-reported data collected in this study are subject to recall and social desirability bias. We attempted to minimise response bias by using computerised, selfadministered survey methods, an effective strategy to minimise the potential for underreporting of risky and stigmatised behaviours [73][74][75]. We chose to employ a single composite risk variable as the outcome of interest in the multivariable analysis since the proportion of those who reported having engaged in any of the six injection-associated risk behaviours was relatively small for most risks, and we didn't wish to increase the potential for type I error associated with multiple comparisons. This decision does not account for the fact that some behaviours are riskier than others and limited our understanding of the specific risk behaviours most likely associated with injection venue. To offset these potential limitations, we included the results of bivariate analysis for each risk behaviour in Table 2. Finally, because all participants resided in nonurban towns, no conclusions can be made about the differences between PWID residing in urban versus nonurban areas. The question of whether the harm reduction information and prevention needs of nonurban PWID differ from those of their urban-dwelling counterpart should be explored in future studies as should the specific contextual factors and risk dynamics that are associated with engaging in injection-associated risk behaviours, particularly for those who inject most often in urban locales and females. --- Conclusions We have previously noted that PWID residing in nonurban locales are in need of the HIV, hepatitis, and overdose prevention information but do not appear to be accessing traditional harm reduction programs [45]. The data suggest the need to expand harm reduction services to nonurban locales. Novel strategies such as pharmacy-based, home delivery, and peer-led interventions should be considered as other means of expanding harm reduction initiatives in nonurban settings. The positive association between HCV infection and length of injection career has been noted previously in published accounts of our study [44] as well as in a recent meta-analysis of data on urban PWID [44,76]. These findings underscore the continued and urgent need to intervene as soon as possible with new injectors in order to provide them with harm reduction information and services. --- ---

Introduction and Aims-Little is known about injection-associated risk behaviours, knowledge and seroprevalence of viral infections among people who inject drugs (PWID) in nonurban locales in the US. Harm reduction services are more available in urban locales. The present study examined a cohort of active PWID residing in non-urban areas of Connecticut to investigate how primarily injecting in urban or non-urban areas was associated with injection-associated risk behaviours, knowledge and prevalence of blood-borne viruses Design and Methods-We described the sample and performed bivariate and multivariable analyses on injection-associated risk behaviours, HIV/hepatitis/overdose knowledge, and baseline serological data to identify differences between individuals who injected primarily in nonurban locales and those who did not. Results-Harm reduction knowledge and use of harm reduction services were poor in both groups. Those injecting most often in urban settings were 1.88 (1.19, 2.98 95% confidence interval) times more likely to engage in at least one injection-associated risk behaviour than their nonurban counterpart. Seroprevalence rates (23.6% for hepatitis B virus, 39.2% for hepatitis C virus, and 1.1% for HIV) were no different between the two groups. Discussion and Conclusions-The data provided little evidence that the benefits of urban harm reduction programs such as syringe exchange, risk reduction interventions, and education programs have penetrated into this nonurban population, even among those who injected in urban locales where such programs exist. Harm reduction interventions for nonurban communities of PWID are needed to reduce HIV and hepatitis B and C transmission.

Commsphere: Jurnal Ilmu Komunikasi, Vol. 1, No. I, March 2023, pp. 1-9 ISSN 2987-1360 DOI: 10.37631/commsphere.v1iI.855 disseminating information about the Korean Wave makes it easier for anyone to access information about this so that it attracts many fans and takes an interest in K-Pop culture itself. One of the Korean Wave products in great demand, especially for millennials, is pop music or K-Pop. One of the most popular entertainment products has lifted the economy of South Korea. Because the South Korean government itself pays special attention to the K-Pop industry, which can be seen from the phenomenon in the late 1990s, when most countries in Asia experienced a financial crisis, but South Korea formed the Ministry of Culture with a special K-Pop department . K-pop became a sensation in Indonesia and became popular in the 2000s. Many boy groups and girl groups are becoming known in Indonesia. In this way, K-pop's prominence in Indonesia has formed a large and solid fan base. Fandom itself is formed because of relationships between people who like the same thing, even formed without intense fan culture and behavior or even not knowing each other . The country of Indonesia is one of the homes for millions of K-pop lovers , with the fourth largest population in the world after the United States of America . The Twitter account announced a list of countries that tweeted the most about K-Pop artists throughout 2019. Indonesia was ranked 3rd after Thailand and South Korea . Apart from that, for viewing Youtube videos about K-Pop by country, Indonesia also occupies the second position with a percentage of 9.9% . Fans or fans are understood as a term to refer to a community or group that has the same passion for popular culture. Fans are usually associated with fanaticism or excessive liking. Referring to Stuart Hall's thought that fans have the autonomy to give meaning to every text they consume. Instead of assuming that fans are passive parties, Stuart Hall's theory positions fans in the opposite direction, namely, seeing fans as involved parties in producing meaning. However, this does not require the possibility that the younger generation will develop some overly fanatical attitudes toward their idols, so this fanaticism will affect the lifestyle of their fan culture . Quoting from the Kumparan survey with data, 56% of K-Pop fans spend 1-5 hours using their social media to access information about their favorite idol, even up to 28% spend six more hours using their social media to see various activities of their idols . So that with this phenomenon, most people or non-fans think K-Popers are always excessive, crazy, hysterical, obsessive, consumptive, or even too generous towards their idols because they like to waste their money on buying something related to their idols. Such as merchandise ranging from albums, photo cards, and lightsticks, or even chasing their idols wherever their idols go . For example, the Commsphere: Jurnal Ilmu Komunikasi, Vol. 1, No. I, March 2023, pp. 1-9 ISSN 2987-1360 DOI: 10.37631/commsphere.v1iI.855 Super Junior group has the fandom name Elf, the Bigbang group has the fandom name V.I.P., and IKON has the fandom name IKONIC. However, among the many K-Pop idols currently widely known, B.T.S. can still survive as a boy group with immense fandom worldwide. A K-Pop group that has achieved success on the international music scene. Currently, they have fans or supporters who are strong and have a considerable influence, which is called ARMY . BTS was founded in 2013 by BigHit Entertainment Agency. BTS began to be in demand after getting the achievements after releasing several albums that could climb the billboard charts, starting with the album Love Yourself, followed by other songs such as dynamite, Butter, and many more. Furthermore, it is increasingly being looked at after the "Love Myself" campaign with UNICEF, which has the aim of helping end all acts of violence and fostering self-confidence and more compassion for oneself and others . So that they can invite their audience, especially their followers, to be aware of mental health issues. This success is inseparable from the influence and support of its fandom, namely the ARMY. Thanks to their supporters, BTS also won international awards, which made BTS even more recognized, such as the Favorite Social Artist American Music Award 2018 and the Top Social Media Artist 2018 Billboard Music Award. The fandom even won the Best Fan category award at the 2018 Kids Choice Award and the most fans at the MTV Europe Music Award. In 2019, at the American Music Awards, BTS was named the winner of Favorite Duo or Group Pop/Rock twice in a row and Tour of the years . Changes in fandom culture and behavior in the digital era have made fans use the internet to connect with fans even though they are in different spheres, known as cyber fandom, by sharing information that anyone can access anywhere . Cyberfandom is a fan group created virtually via the internet or social media, making it easier for fans to connect with each other and share or access information related to their idols. As part of the fandom of BTS, ARMY uses social media to carry out its activities to interact with other ARMY. One of the social media is Twitter. One Indonesian ARMY fanbase account, namely @INDOMY, was created in November 2017 with 200,392 followers and 32,916 thousand tweets. Seeing this indicates that activities for mutual interaction are very often carried out between ARMY. In his account, we can see how the admin provides information about BTS, such as new song releases, concert schedules, voting at award events, or other activities carried out by BTS members. So fans can interact with each other. Fanbase accounts aim to make a more comprehensive community that can recognize their favorite idols and are more popular on the international stage. With a fanbase account, audiences will find it easier to find the latest information about their idol's activities, such as new album releases, the information of Commsphere: Jurnal Ilmu Komunikasi, Vol. 1, No. I, March 2023, pp. 1-9 ISSN 2987-1360 DOI: 10.37631/commsphere.v1iI.855 music video teaser releases, concert schedule information, or even voting information when their idol is nominated in an award event, so fans will try to vote. In various ways so that they are in the first position and win the award. Seeing this phenomenon with various virtual activities carried out by ARMY and technological advances, the authors are interested in researching the ARMY fandom to see how fan culture is in the digital era on the @INDOMY Twitter fanbase account. This is reflected through various response activities, and the production of messages online on social media Twitter @INDOMY. --- RESEARCH METHODS This study uses a virtual ethnographic method. Using this method, researchers become part of the subject by following fans' activities in cyberspace. Moreover, researchers are part of the ARMY @INDOMY fanbase account followers on Twitter media. According to Rusli , virtual ethnography is a method used to view users' social or cultural phenomena in cyberspace. Even Bell states that this ethnographic method is leading and essential for viewing online cyberculture phenomena. Christine Hine in Nasrullah states that virtual ethnography is a methodology used to investigate the internet and explore identity when using the internet. Of the many Indonesian ARMY fanbase accounts, the researcher chose the Twitter account @INDOMY as the research subject for approximately three months, from November 20, 2022, to January 10, 2023. This account is said to be an Indonesian ARMY fanbase account because of the username used and posts containing various information about BTS and ARMY, with 200.392 thousand followers and tweet posts that have reached 32,916 thousand tweets. This research focuses on all texts and media fans post on the @INDOMY Twitter fanbase account when carrying out fan culture. Two data collection techniques are used, namely observing the @INDOMY fanbase account and literature review of previous research as additional data to complement research information needs. --- RESULTS OF RESEARCH AND DISCUSSION Based on the formulation of the problem above, the researcher wants to know how the fan culture of the ARMY fandom is presented through Twitter media in the digital era on the @INDOMY account, with various activities, ranging from mutual commentary responses, replying to each other's uploads made by the ARMY fandom, research finds various forms of culture Fandom can be seen from four forms, namely communication, knowledge creativity, and civic organization or power . Commsphere: Jurnal Ilmu Komunikasi, Vol. 1, No. I, March 2023, pp. 1-9 ISSN 2987-1360 DOI: 10.37631/commsphere.v1iI.855 The ARMY fandom communicates virtually through social media, Twitter, with the same identity, namely ARMY. Where they are put together in the fanbase account, their virtual identity can be seen from their name, profile photo, id name, photo background, and bio of each account. The picture above shows BTS fans, namely the ARMY, showing their identity as a fandom, one of which uses attributes related to their idol. It can be seen that most of them use profile photos of BTS members, not their photos, and the username shows that they also use the modified BT member's name as their account. This behavior is in line with what was conveyed by Pertiwi , where a person's identity in cyberspace may be different from the original. In the world of fandom, communication made within the scope of fandom is usually only understood by the members of the fandom itself, which is referred to as fan speaking. This fan can be in writing or symbols, which can be understood by the fandom itself, even in the virtual world, like "love purple", where this sentence is interpreted as a purple heart, a feeling of love and strength between BTS members and ARMY. In the field of creativity, it can change people's mindset in viewing fans, especially K-pop fans. If previously fans were called hysterical people, too fanatical about their idols, and even called crazy, with this creativity, fans also have positive things in them. Because fans also act as an active audience in interpreting a text, creative ideas are created in it. Because fans become audiences, who consume what is presented by the media and through the textual meanings of media content, they are also actively involved in producing meanings that they implement through their works. These fan works are called fan production or a product fans produce. Fans, as audiences, will take imitative actions and produce culture Commsphere: Jurnal Ilmu Komunikasi, Vol. 1, No. I, March 2023, pp. 1-9 ISSN 2987-1360 DOI: 10.37631/commsphere.v1iI.855 after consuming cultural texts left by the media . Fan production, created by fans, is diverse, including memes, fan edits, fan fiction, and many more. One form of creativity that fans produce is "editing," which makes it more interesting. Fans do this for fun and to generate interaction between fans on the account. 2014). A fan project is a project carried out by a fandom to support their idols and stream to increase their idol's MV viewers, so they enhance each other for streaming because usually, in a fandom, they have goals when their idol releases the latest MV. They also carry out digital activities to celebrate their birthdays, such as fundraising, called fan donations, which are intended for underprivileged or disaster-affected communities using social media. This creates a new culture in fandom in activities or fandom activities that are carried out in a coordinated manner in a fan project so that the fanbase account is significant in the world of fandom, which aims to provide various information so that communication, interaction between fans is created in the fanbase account. --- CONCLUSION With the development of internet technology in fandom activities, social media plays a role in disseminating information about the Korean Wave, making it easier for anyone to access information about their idols. Commsphere: Jurnal Ilmu Komunikasi, Vol. 1, No. I, March 2023, pp. 1-9 ISSN 2987-1360 DOI: 10.37631/commsphere.v1iI.855

Korean Pop Culture (K-Pop) has succeeded in spreading its cultural products popularly to the international world. This process is known as the "Korean Wave" or "Hallyu". Korean Wave is a term for spreading Korean popular culture through industrial products such as music, style, drama, fashion, etc. The process of its spread cannot be separated from technological advances and the existence of social media such as Instagram, Twitter, TikTok, YouTube, and so on, so it can be said that social media is the primary channel for the emergence of the Korean Wave phenomenon (Purwanti, 2013). With social media,

INTRODUCTION Among the profusion of encounters faced by learners in Amathole East District of the Eastern Cape Province, specifically those attending public schools settled in rural settings, is Lesbian, Gay, and Bisexual -based school bullying. Consequences of this are blamed on fist-tightness of teachers in offering LGB-based sexuality education to learners in their early stages of upbringing, while on the other hand, UNESCO observed that LGB-based bullying among senior-phase learners is driven by the stigma and biases emanating from cultural beliefs about gender roles, masculinity, and femininity. That is, elders' indoctrination of the qualities and responsibilities of each gender causes those who still follow suit to look down on those who associate themselves with LGB. This has led to episodes of bullying cases, including but not limited to discrimination, humiliation, physical assault, and sexual results in appearance misconceptions and difficulties in befriending other learners in the school setting . It also emerged that Nigerian schools foster heterosexuality through homophobic views and rules with the intent of marginalizing the LGB lifestyle , which belittles the already minoritized group. Hence, the scholar observed the imperativeness of implementing culturally sensitive anti-bullying programs to ensure the safety of LGB learners. In Ghanaian schools, LGB learners are deprived of participating in democratic domains since they are not among the majority group -heterosexuality . This raised uncertainties about their sexual orientation . Rimes et al. observed an increased suicide rate among LGB learners who were victims of stigma-based victimization. In the case of South Africa, irrespective of the constitutional rights that were documented with the intent of protecting previously marginalized sexualities, including LGB groups, homophobic bullying is still extensive to a prodigious level . The reason underlying this endless discrimination, stigma, and demonization of learners who conform to LGB identity may be the fact that the South African constitution did not document laws that directly focus on minority groups. However, it included them in Section 9, which includes all South African residents . This has resulted in a couple of the most common forms of discrimination, namely: verbal bullying as well as violence threats and vulnerability to heterosexism on a daily basis , where LGB learners are still perceived as inferior compared to heterosexual learners. As much as there is no concrete evidence or indication of higher levels of bullying among LGB learners when compared to heterosexual learners, the Legal Resource Center observed that LGB learners across the country encounter homophobic bullying, not only from their peers but also from their teachers, who were supposed to maintain classroom safety for each individual learner without considering gender diversity. This causes LGB learners to avoid talking about being bullied, as Rhodes University mentioned that LGB learners have no role model to talk to and no teacher to offer support, so they end up being suicidal, anxious, and depressed, which negatively affects their self-esteem and academic performance. In efforts to diminish LGB-based bullying in South African schools, the Department of Basic Education implemented an inclusive school safety framework that aimed to challenge bullying in general . The fist-tightness of scholars conducting research on LGB-based school bullying in the Eastern Cape Province resulted in limited literature about the phenomenon. However, Staff Reporter on IOL reported that the Eastern Cape is the most homophobic province in South Africa, yet violence against LGB individuals is more prevalent. Rumormongering is a form of bullying that targets LGB learners, as a learner was being rumored and accused of being capable of raping other learners since she identified herself as a lesbian . On the other hand, most educators and administrators were brought up in a society where LGB was perceived as sodomite, traditionally inappropriate, and transgressive. Although all these proposals have been instigated, cases of LGB-based school bullying and its effects are severe. The above literature divulges that the root of the stigma, misconceptions, misjudgments, and biases towards LGB learners that lead to their victimization is the lack of sexuality education, especially based on sexual orientation. Furthermore, people are still holding onto the beliefs and laws that were enacted to marginalize LGB instead of embracing the modernized era. As the key to nearly everything, several studies observed that teachers could play a vital role in combating LGB-based bullying with proper training and adequate resources since they will offer the education necessary for learners to understand various sexualities, speak against homophobic comments, and instil morality among learners. As much as South Africa prides itself on its constitution being the "first in the world to prohibit unfair discrimination on the grounds of sexual orientation, hence guarantees lesbian and gay equality" , literature revealed that cases of bullying that lead to severe effects, including suicide, are still prevalent among LGB learners. --- PROBLEM STATEMENT Numerous studies conducted recently in various countries concluded that LGB learners experience a disproportional amount of bullying when compared with their heterosexual peers. This results in them experiencing lower life satisfaction , physical health problems , intolerance, discrimination, harassment, and violence regarding their sexual orientation . American Psychological Association believes that these hitches lead to learners' negative psychological effects, including depression, which hamper their classroom concentration and academic performance. On the other hand, Richardson and Wallstead in the classroom contributes to LGB-based bullying, which is blamed on discriminatory curriculum and textbook chapters that do not contain adequate information for teachers to facilitate learners with. That is, curriculum planners' refusal to include LGB-based sexuality education in the curriculum only enhances the escalation of homophobic behaviours towards learners whose birth sex is not in line with their gender specifications. Furthermore, teachers' fist-tightness in conversing or talking about important aspects of homosexuality, including LGB, endangers LGB learners since heterosexual learners will continue to embrace prejudice and misconceptions about their sexual orientation. To this end, it is significant to investigate issues that limit schools from combating LGB-based school bullying and seek methods to combat it. --- RESEARCH OBJECTIVES For the researchers to successfully analyze LGB-based school bullying, the following research objectives were implemented: • To investigate the limitations of schools in combating LGB-based school bullying, • To determine methods of combating LGB-based school bullying among senior-phase learners. --- THEORETICAL FRAMEWORK For researchers to thoroughly analyze LGB-based school bullying, this study was underpinned by two theories. Social Stigma Theory entails an in-depth nature of stigma-based bullying and the Anti-Bias Education Approach, which fosters learners to familiarize themselves with gender diversity and speak against prejudicebased discrimination. --- Social Stigma Theory Erving Goffman Social Stigma Theory elucidates stigma as the slandering of someone's character through unpleasant name-calling. Among the three forms of stigma that were detailed by Goffman is blemished individual character, which includes LGB-based stigma. When revealed, this form of stigma may result in anxiety, a ruined reputation, and lifelong negative effects on the stigmatized individual . Nyasulu observed that qualities regarded as triggers of stigma are inculcated in societal members, leading to discrimination should one reveal those qualities. In a similar vein, Earnshaw et al. asserted that influences that result in stigma-based bullying descend from the societal level to the interpersonal level and down to the individual level. That is, stigma-based bullying does not emerge from a random internal motive but is a descendant of a societal perspective that is meant to instil a certain doctrine among its inhabitants, which is the wheel that rotates from ancient humans towards the present generation. This theory is relevant to this study because LGB-based school bullying is a social phenomenon that is influenced by the societal indoctrination of qualities and responsibilities that are perceived to be normal for a certain gender, which induces heterosexism and results in learners' disapproval of LGB relationships. For instance, people resembling the dominant cultural group in the Eastern Cape Province believe that a man is responsible for the continuity and preservation of his clan by marrying a woman who will eventually bear children. So by identifying as LGB, they are convinced that a man is transgressing this social doctrine as men cannot bear heirs, which will probably inculcate the extinction of that particular clan. By exhibiting gay qualities, society concludes that one is no longer a man and does not deserve their respect, and they constantly remind them in a vulgar manner, which is imitated by children and practiced among LGB learners at school. This results in social exclusion, name-calling, assaults, and other forms of bullying, including spreading rumours about LGB learners. This incites self-doubt and self-hate for the stigmatized to the extent of make them anxious, depressed, drop out of school, and even consider ending their lives. This gap further led to the adoption of an anti-bias education approach to encourage learners to accommodate gender diversity. --- Anti-Bias Education Approach Anti-Bias Education Approach was proposed in 1989 by Derman-Sparks and Edwards with the intent of creating and maintaining a tranquil school environment by nurturing learners to understand and demonstrate positive personal and social identities, familiarizing learners and promoting comfort with human diversity, encouraging them to recognize unfairness, and empowering them to stand against discrimination . Sparks believes that young schoolgirls are cognizant of privilege and power-connected factors, including gender. Hence, they proposed ABEA and encouraged teachers to embrace and facilitate learners with Anti-Bias Education to create a community that will be supportive of all scopes of human variables, including sexual orientation . This approach is relevant to this study because, when applied to seniorphase classrooms, it will not only introduce the concept of diversity to learners. However, it condemns LGB-based school bullying since the levels of misconceptions and discrimination targeted at LGB learners will be neutralized by encouraging learners to understand, accept, and support various sexual orientations, most importantly LGB. Furthermore, the application of ABEA will enable learners to be proud of who they are. It is, therefore, imperative for curriculum planners to include Anti-bias education in the curriculum for teachers to introduce it at learners' lower phases of education. This will disarm heterosexual learners' minds from misconceptualizing LGB and holding on to the mentality that LGB is among the minoritized group while fostering their ability to speak against LGBbased discrimination in their respective schools and communities. --- METHODOLOGY This study adopted a qualitative research approach, an interpretivism paradigm, and a case study design. Data were elicited from purposively sampled participants using in-depth interviews, and researchers analyzed raw data in the form of recordings and notes with Braun and Clarke thematic analysis to classify emerging themes and make sense of the data. Researchers acknowledged and adhered to the principles of research ethics. --- Research Approach, Paradigm, and Design This study adopted a qualitative research approach to collect detailed non-numerical data and to understand the perceptions and experiences of the sampled participants. Researchers aim to utilize participants' LGB-based school bullying perceptions and experiences to produce new concepts and themes and to observe participants' feelings and behaviour to make sense of their experiences for research purposes . This study is lensed through the constructivism paradigm because the researchers seek to elicit various descriptive self-constructed ideas and perceptions about LGB-based school bullying from participants since constructivists believe that each individual constructs reality based on experiences and feelings regarding a particular phenomenon. Furthermore, researchers' intent is pinned on analyzing LGB-based school bullying, which can be done by placing themselves in the participants' thinking to reconstruct the intended meaning . This study is designed as a case study since researchers aimed to investigate an indistinct phenomenon within its actual setting . Furthermore, researchers employed a case study design to explore LGB-based school bullying through the views and reactions of participants who live their daily lives in the setting where the phenomenon occurs . This design also helped the researchers dig through the phenomenon at hand to gain an in-depth insight that later enabled us to identify ways in which the study objectives could be accomplished. --- Sampling and Instrumentation For researchers to elicit data that served the purpose of this study, a non-random purposive sampling technique was utilized. This technique allowed researchers to identify and hand-pick samples that possess rich knowledge or experience regarding LGB-based school bullying . 09 participants, consisting of 4 senior phase teachers, 2 female learners identifying as lesbians, and three male learners identifying as gays from one Secondary School, were selected to participate in this study by responding to a series of interview questions. Researchers conducted one-on-one, in-depth interviews with 09 purposefully sampled participants. The objective for the utilization of this instrument was to elicit detailed and authentic data based on participants' perceptions and experiences about LGB-based school bullying in a relaxed and unhostile atmosphere and without being influenced by others. Moreover, this instrument enabled probing for more detailed enunciations to avoid researchers' assumptions and preconceptions. --- Data Analysis and Ethical Considerations The thematic analysis technique was utilized since it enabled researchers to code raw qualitative data gathered from the participants into analogous themes to construct a coherent theoretical elucidation of the phenomenon. These themes were then aligned with the study objectives . Analysis and interpretation of the primary data were done by adopting the universally acknowledged six-steps thematic analysis techniques. These steps, according to Braun and Clarke , involve reading through the data for familiarization, encrypting the data into themes, identifying related themes, revising themes, naming themes, and constructing theoretical elucidation. Creswell asserted that researchers are bound to respect participants' rights, desires, and values. Therefore, to be in line with the scholar's assertion, researchers recognized and followed Walter Sisulu University's ethical considerations, which include valuing the rights of the participants, confidentiality, anonymity, consent, and permission for participation. To ensure this, it was thoroughly explained to each individual participant that they were not obliged to participate and that they were free to withdraw their participation from the study should they need to Omodan . Moreover, each participant was assigned a fictional name to ensure his or her anonymity. A male teacher was coded as LM; female teachers were coded as TF; female learners were coded as LF; and male learners were coded as LM. Lastly, minors were given consent forms to be signed by their parents. --- RESULTS AND DISCUSSION The findings of this paper were discussed based on the study objectives and themes that arose from the data elicited from sampled participants. --- Limitation of Schools in Combating LGB-Based Bullying Among Senior Phase Learners To respond to the first objective, which is the limitation of schools in combating LGB-based bullying among seniorphase learners, the following themes emerged: Ignorant and Unsupportive Teachers; LGB is not recognized; Consistency to religion; Indistinct and no LGB-based bullying reports; Usage of same facilities as heterosexual learners. --- Ignorant and Unsupportive Teachers Teachers' unwillingness to intervene in LGB-based school bullying is identified by their ignorance when learners log LGB-based bullying cases. LGB learners and parents entrust teachers with the responsibility of being the primary protectors and conflict-resolution mechanisms among all learners in the school environment. If this protection is unilateral, that is, it is only applied to the heterosexual group, this indicates that the LGB populace will suffer all the consequences of having their claims ignored, which include continuous harassment. LF2 and LM1 shared the same emotion: LF2: "No one cares about us here. For example, I reported that learners say I have a snake, and some teachers asked if I really have it. I said no, I don't have it, and they told me to go back to the class and don't mind what they say. At least they should have called them and said something or punished them for that, but they never did, and those learners never stopped saying, I have a snake." LM1: "Even if we report, some teachers just joke about those things and never punish or call the learners that bully us to explain why they are saying those things." Participants demonstrated dissatisfaction with teachers' ignorance of their reports. The statements above indicate teachers' unwillingness to intervene and take necessary steps to follow up on LGB-based bullying cases logged by LGB learners. In the accusation reported by LF2, one can conclude that heterosexual learners link LGB with witchcraft, which according to South African law is a criminal act since an accusation of this nature mutilates one's reputation, especially if the accuser has no concrete evidence. She further claimed that no action was taken to discipline such behaviour. Instead, teachers told her to ignore such wicked allegations. In a similar vein, LM1 told us that teachers joke about their reports instead of intervening. Despite all the dreadful allegations made by heterosexual learners towards LGB learners, teachers remain unbothered and reluctant to apply rational procedures to the culminate misdemeanor behaviour exhibited by heterosexual learners; instead, they find amusement in it. It is also evident that teachers do not even confront and punish learners who spread rumours about LGB learners. This might be the result of teachers' shortsightedness in spotting the severity of verbal bullying . Hence, due to a dearth of support and protection, school stakeholders are unknowingly inspiring never-ending episodes of LGB-based school bullying since heterosexual learners will not consider their actions unacceptable. These findings are compatible with the claim of Mueller, James, Abrutyn, and Levin , who discovered that teachers ignore their claims when LGB learners log incidents of victimization. --- LGB is not Recognized Participants informed the researchers that school stakeholders do not acknowledge LGB, which results in the school community forgoing anything regarding LGB. DePalma and Atkinson and McShane and Farren observed that the dearth of dialogue among school stakeholders about LGB-based matters indicates stakeholders' passive behaviour. This observation is evidenced by several participants: TM: What really challenges us in addressing this type of bullying is the fact that we do not want to admit that here at school, we have learners who associate themselves with LGB. It is not even easy for us to talk about it because, to me, it feels like we will be introducing them to it or motivating them to become lesbians and gays, and parents will see us as bad people as we are supposed to be moulding their children and not introducing them to something that is not acceptable to them. TF1: The school treats all learners as they are, like males are treated as males and females are treated as males. We never considered treating LGB learners differently. TF2: To be honest with you, I have been here for four years, and I have never heard any mention of LGB learners, so I can say that the school is not playing a remarkable role in protecting them from being bullied by straight learners. TF3: The school only addresses general bullying, not bullying that is specific to a certain group. For example, last year, the principal called all parents and guardians to discuss the bullying that was happening here. They only mentioned a few forms of bullying but never mentioned LGB bullying. No one has ever spoken about it at school, even though some of our learners bring cases of LGB bullying to us. According to these assertions, participants affirmed that teachers avoid discussing LGB-related matters at school among the plethora of challenges they encounter in their attempts to manage LGB-based school bullying. This divulges the fear that teachers may be galvanizing learners' inquisitive minds into adopting these previously minoritized genders, which will intensify the number of LGB learners in their respective schools. Moreover, this school only addresses all other forms of bullying except bullying that involves LGB. The school's silence concerning LGB-based school bullying indicates that LGB is still considered one of the minoritized groups and treats it as if it was never supposed to exist in their respective school, especially since the school is situated in a rural area. Even if there is one empathetic school stakeholder who would consider intervening in LGB-based school bullying, she/he will be demotivated since other stakeholders will not be supportive of his/her attempts. The school will continue to be a hotspot for LGB-based bullying since Atkinson affirmed that silence about LGB conveys the message that LGB is not recognized. --- Consistency to Religion Adaptation and consistency to certain religious beliefs are unveiled as another obstacle for stakeholders to manage LGB-based school bullying. This is because their religious beliefs prohibit them from protecting and supporting genders believed to have been cursed hundreds of years ago. These beliefs, according to Street , are covertly allowing LGB-based perpetration. Participants said: TF1: "Juliet, most of the teachers here are churchgoers; they believe that Jesus destroyed Sodom because of issues, including this LGB thing. It is against their religion to stand for something Jesus Himself considered a sin and intended to destroy. So, I can say that is one of our difficulties. They cannot condone something that they preach against at church." TF2: "The school still has old teachers who think that LGB is Satanism, so if I speak to them about anything related to LGB, they do not consider it important." Participants complained about old teachers' unwavering consistency with Christianity, which precludes them from intervening in LGB-based bullying among senior phase learners. As stated by TF1, these teachers are absolutely against homosexuality since they believe in a hypothetical Bible interpretation stating that Jesus destroyed Sodom because it was home to sinful acts, same-sex coupling included. Hence, they relate LGB with Satanism since they associate sinful acts with Lucifer, who is believed to have a bad influence on people. These views are similar to those of an expelled East London teacher who, according to Milton report on Pink News, claimed that LGB learners have Satan's deoxyribonucleic acid . The fact that teachers put their religion first instead of learners' welfare is surprising. It has been unleashed that teachers repudiate standing up for victimized LGB learners because their religion forbids same-sex relationships, while the South African Council for Educators ordered teachers to uphold and promote basic human rights as embodied in the South African Constitution. These rights include offering uniform support and protection from maltreatment to each individual learner without a second thought. In the professional world, teachers must be the main stakeholders who fight against discrimination and maltreatment of any learner, irrespective of any circumstance, instead of putting their personal interests first. --- Indistinct and No LGB-Based Bullying Reports Limiting schools endeavors to manage bullying among senior-phase learners is indistinct, and there are no LGBbased bullying reports. Inadequate information produced by the victims of bullying is reported to be limiting school stakeholders investigation grounds in the cases brought to them. On the other hand, learners blame their teachers for being judgmental. Below are participants' statements: TF1: "The other thing is that these learners do not usually come to us and report what happened to them, but we hear rumours that lesbian or gay learners were involved in a mass fight after school or before school. So, it is not easy for us to deal with hearsay." TF2: "Learners do not give us full reports of what happens to them or what has been posted about them, irrespective of how hard we try to interrogate them. Some don't even report the case, making it difficult for the teachers to intervene in such issues because we do not have the main problem to work on." LF1: "Most learners who are among the LGB community are still scared of expressing themselves because of what others will say at school. At school, learners are judged of their gender. We are not only bullied by learners in our grade and in our age bracket; for instance, I was bullied by a grade 11 learner, and when I said I was going to report him, he said maybe I was going to use an underground tunnel when um going home should he be punished for that. I did not report him because I was afraid of him and was not even sure he would be punished because no one takes LGB seriously at school." LF2: "I can say that we are limiting the school because most of the time we don't report bullying to the teachers because they can be judgmental, they gossip about us liking things, they can just even call you to fetch them water kanti they want to show others that it is you that they were gossiping about. If we were not going to be judged, it would be easy for us to approach our teachers, and if they would be more open about anything that happened to us." LM2: "Some bullying cases happen on social media ma'am, so we don't take that to school; we only attend it on social media unless some learners confronted others here at school and teachers saw them or someone went to report. Otherwise, most of us do not report things that happened on social media because they are too rude." Participants echoed the first tightness of learners in reporting LGB-based school bullying, resulting in teacher's inactivity in intervening in LGB-bullying cases. TF1 and TF2 elucidated that it is difficult to intervene in cases they are not so certain about because LGB learners are even more difficult to interrogate. They do not want to reveal the nature of the incident. As affirmed by LF1 and LF2, schoolteachers' judgment induces the fear of giving full reports about bullying instances because they believe they will be exposing themselves to never-ending gossip and attitudes exhibiting bias and prejudice by teachers towards them. Similarly, Ngcobo reported that learners do not have confidence in being transparent about LGB-based issues to their teachers since they fear being judged. On the other hand, learners do not report cyberbullying because exchanging vulgar comments on social media is a misdemeanor, which may be embarrassing when shared with teachers. This is one of disadvantages of learners' accessibility to mobile phones, especially at immature stages. LF1, on the other hand, articulated that she did not report bullying because she was threatened by a higher-grade learner and thus feared further perpetration. Based on this analysis, LGB learners corroborated teachers' affirmations that they do not report LGB-based bullying. However, the reason for LGB learners to encapsulate almost all the LGB-based bullying incidences is to point at teachers' reactions towards learners who identify as LGB. Misjudgments and endless gossip about LGB learners, which result in a dearth of trust towards teachers, discourage them from reporting this bias-based bullying since they believe that their cases will not be investigated and resolved. These findings support Kolbert et al. , who observed that learners are short at reporting bullying cases because they are anxious about being victimized, and their teachers are incompetent at intervening in bullying cases. --- Usage of Same Facilities as Heterosexual Learners The absence of LGB facilities in school is evidenced to induce LGB learners' feelings of being in a non-inclusive and unsafe environment, raising insecurities about their identities. Kosciw et al. also affirmed that LGB learners avoid utilizing school bathrooms because of their hostile nature. Hence, sharing the same bathrooms with heterosexuals is among schools' limitations in managing LGB-based school bullying. This is exemplified by LM3's statement: LM3: "The thing is, we are using the same toilets with straight boys who always tell us, "You gay, you were not supposed to be relieving yourself with us because we are men, and you are supposed to be wearing skirts". Sharing bathrooms with heterosexual learners exposes LGB learners to bullying to a great extent, as LM3 revealed discriminatory comments made by heterosexual learners when they are out to relieve themselves during break times. He went on to express his feelings towards being feminized by heterosexual male learners. One can conclude that school bathrooms are one of the most popular hotspots for LGB-based bullying, especially among gay learners. We consider this a continuing phenomenon because of their daily physical contact, which results in heterosexual learners uttering unfavorable comments about gay learners. To this end, it is excruciatingly challenging for the school to manage LGB-based bullying because it may not be able to instantly provide toilets only meant for LGB learners. --- Methods to Combat LGB-Based Bullying among Senior Phase Learners The second objective, which is the methods to combat LGB-based school bullying, has the following themes: avoid gender disclosure, create awareness of gender diversity, provide bathrooms for LGB learners, and follow up on LGB-based bullying cases. --- Avoid Gender Disclosure Circumventing being transparent about one's gender is believed to be one of numerous effective methods of combating LGB-based school bullying among senior-phase learners. TF1 stated: TF1: "If learners can stop making noise about who they are, that is, their LGB status, others will not have the reason to bully them." Remaining silent about one's identity is believed to be one of the methods that will end LGB-based school bullying. The more learners do not divulge their identity, the less heterosexual learners will have motives to victimize them. As per this articulation, "making noise" expresses that LGB learners seem not to be hideous or ashamed of their identities, irrespective of how the school community feels about them. Based on the above analysis, motivating LGB learners to stay in the closet and avoid demonstrating qualities that will make it easy for other learners and teachers to identify them as LGB will result in dropping rates of LGB-based school bullying. This is because of the sentiment that sexual orientation disclosure constitutes harassment, discrimination, and victimization since one's gender varies from that of the majority. However, this study conforms to the findings of D'augelli and Grossman , who divulged that after lesbians and gays disclosed their sexual identities, they became vulnerable to being attacked and physically threatened. --- Creating Awareness on Gender Diversity Participants demonstrated imperativeness in addressing learners and teachers about the nature of LGB so they would be comfortable engaging in an open conversation about it and encouraging learners to refrain from LGBbased bullying. Hence, Domínguez-Martínez and Robles recommended that schools have awareness programs to promote respect and counteract discriminatory attitudes towards sexual orientation. Reality supported this recommendation: TM: " The first statement demonstrated the inarguable imperativeness of encouraging teachers to accept and uniformly treat every bullying case before encouraging learners to report LGB-based bullying. On the other hand, TM, advocated by TF3, proposed that there must be days set aside to have a word with learners to refrain from biasbased school bullying and encourage LGB learners to report all the bullying incidents distinctly. LM2 and LF1 advised the school to have awareness sessions where LGB specialists will capacitate learners with every important detail about LGB and, most importantly, to encourage them to understand that LGB is natural, just like any other gender. Talking sessions will broaden positive school stakeholders' perspectives on diverse genders, prepare them to speak freely about LGB, and plant the belief that these genders are not as dangerous as they are rumored to be. Moreover, this will persuade the demarginalization of LGB in rural schools, and at least the school-going population will have remarkable influence in their communities regarding the demarginalization of LGB. Furthermore, this will decrease the rate of bias but improve LGB learners' freedom to participate in schools' extramural activities and their academic performance since they will no longer be anxious about bullying. This finding conforms with Cymru study suggesting fostering transparent discussion with learners and teachers to meet the needs of LGB learners, enabling teachers to deal with sexual orientation-related issues honestly and without judgement, and providing opportunities for heterosexual learners to understand diverse genders. --- Providing Bathrooms for LGB Learners Decision for rural schools to construct bathrooms for LGB learner's sounds like a clever method to separate LGB learners from heterosexual learners and give LGB learners the desired safety and security. Thus, the Council of Europe considers learners' inclusion in policy-making a virtuous method since they will be able to address relevant issues, including choosing appropriate bathrooms. LM3 suggested: LM3: "I think if we can be separated from straight learners like we have our own toilets that will make LGB bullying better because it will be the only way to avoid them because they mostly bully us in the toilets and in break times." Segregating heterosexual learners from LGB learners through the provision of special facilities for LGB learners is believed to be one of the bullying management methods since, according to LM3, when they use their own toilets, there will be no conveyance of biased comments since they will avoid physical contact with heterosexuals. The provision of special facilities for LGB learners is perceived as a long-term solution. However, its implementation may take years, especially in public schools, since school stakeholders must first file requests with the government and explain the undesirable effects of not having these facilities. The provision of these facilities will not only be a management strategy for LGB-based bullying but also a welcome note and sign of acknowledgement for all LGB learners. --- Follow-up LGB-based Bullying Cases Courage for school stakeholders to intervene and act towards disciplining learners that engage in LGB-based bullying will be advantageous for LGB learners as they will be almost free from victimization based on their gender identity. That's the reason Cymru suggested consistent and effective responses to LGB-based bullying cases, which will assure LGB learners that their cases are taken seriously. LF2 articulated that: LF2: "The school needs to take LGB bullying seriously by following up on the cases and not letting learners just go without punishment so that they will know that bullying is wrong for everyone." LF2 observed that the school does not consider LGB-based bullying a crucial phenomenon that requires the school's attention. Hence, she suggested that this type of bullying must be thoroughly addressed and punishable. This will serve as a lesson for all heterosexual learners who intend to bully LGB learners: whatever bullying method is used, it is unacceptable. Based on this analysis, there is undying trust and belief that teachers can play a crucial role in freeing learners' minds from misconceptions and biases towards LGB learners. This can be achieved by --- practicing their power and adhering to government laws that enforce them to protect and advocate for learners when necessary. Similarly to this finding, the Department of Basic Education recommends immediate intervention, an investigation of the nature of the incident, and disciplining those involved. --- CONCLUSION AND RECOMMENDATIONS The study explored the limitations of schools in managing LGB-based bullying and investigated methods for combating LGB-based school bullying in secondary schools. Using the principles of interpretivism paradigm, the study concluded that inadequate teacher support and protection, LGB not being recognized, consistency with religion, indistinct and no LGB-based bullying reports, and usage of the same facilities as heterosexual learners are limitations that hinder schools from combating LGB-based school bullying. On the other hand, it was concluded that methods such as avoiding gender disclosure, creating awareness about gender diversity, providing bathrooms for LGB learners, and following up on LGB-based bullying cases are strategies to combat LGB-based school bullying. This study has the following recommendations: • Encouraging frequent and transparent catalogues about gender diversity to familiarize school stakeholders with the existence of LGB learners. • Demotivate learners from engaging in LGB-based school bullying by clearly elucidating the consequences they may encounter should they be resilient. • Foster teachers to intervene in LGB bullying cases regardless of gender identification. • Lastly, encourage LGB learners to distinctly report LGB-based bullying reports to enable teachers and other school stakeholders to intervene and resolve their encounters. The researchers suggest further studies that will focus on exploring teachers' attitudes towards LGB learners, which may reveal the root of LGB learners' dearth of recognition and advocacy in their schools. --- STUDY LIMITATIONS The sensitive nature of this study made it difficult for some participants to participate in it. The researchers aimed to have at least 10 participants; unfortunately, some refused to share their opinions with us, especially teachers. --- FUNDING This study received no specific financial support. --- INSTITUTIONAL REVIEW BOARD STATEMENT The Ethical Committee of the Walter Sisulu University, South Africa has granted approval for this study with the protocol number BEEC 2-09-22. --- TRANSPARENCY The authors confirm that the manuscript is an honest, accurate, and transparent account of the study; that no vital features of the study have been omitted; and that any discrepancies from the study as planned have been explained. This study followed all ethical practices during writing. --- COMPETING INTERESTS The authors declare that they have no competing interests. --- ARTICLE HISTORY

Purpose: Despite LGB recognition, recent literature and news reports have evidenced the existence of LGB-based school bullying among school-going adolescents. Through this, learners experience calamities such as anxiety, insecurity, poor academic performance, and even suicide. For this reason, this study investigates the limitations of schools in combating LGB-based school bullying and determines methods to combat LGB-based school bullying. Design/Methodology/Approach: This qualitative study was lensed through Social Stigma Theory (SST) and the Anti-bias Education Approach (ABEA), adopting a constructivist paradigm and a case study design. To elicit descriptive data from the participants, in-depth interviews were conducted with 9 purposefully sampled participants, including 4 senior phase teachers (grades 8 & 9), 2 lesbian females, and 3 gay senior phase learners. Researchers utilized Braun and Clarke's six steps of thematic analysis to make sense of the data. Findings: This study revealed a number of barriers that prevent schools from addressing bullying that is based on LGB among students in the senior phase. These include uneducated and unsupportive professors, the lack of recognition of LGB, adherence to religion, vague and nonexistent claims of bullying based on LGB, and the use of the same facilities as students who are heterosexual. This study also revealed that avoiding gender disclosure, creating awareness about gender diversity, providing bathrooms for LGB learners, and following up on LGB-based bullying cases are methods that can be practiced to combat LGBbased school bullying.This study concludes by recommending frequent dialogues about LGB among learners and teachers to familiarize themselves with its existence. Research Implications: The study identified the need for schools to combat LGB-based school bullying.The study recommends open dialogues on gender diversity, discourages LGB-based bullying, empowers teachers to intervene, and promotes confidence in LGB-based learners. Contribution to Literature: This research contributes to the body of knowledge by identifying and addressing the unique challenges associated with LGB-based school bullying.

INTRODUCTION The emergence of the COVID-19 pandemic in early 2020 has unleashed havoc of its kind on the entire world, affecting almost all aspects of human lives; the higher education system was no different. Primarily, it caused delays and postponement of many physical events and activities, which resulted in a rapid shift of physical teaching to the digital one, leading to the emergence of "New Normality" in the higher education system . This emergence of COVID-19 has brought new opportunities in research collaboration, education, learning, and institutional governance. The higher educational institutes were made to re-think and re-design their overall structure for the modern and dynamic execution of the knowledge dissemination process. With the implementation of immediate changes, such institutes require contingency initiatives and risk-mitigation strategies to continue growing innovatively. Even though this pandemic has forced the higher education institutes to re-form the role of the innovative learning environment through digitalization and to educate, formulate, and induce those innovative skills in the students, which can bring international students to the next level of learning. Besides, the prevailing pandemic has adversely affected the student's personalities because of their physical and technological exposure to the educational institute, and its socio-cultural learning and adaptions. Moreover, the given study highlights the hidden aspects associated with international students' personality development constraints. It also opens the additional avenues for the higher education systems to re-think and re-consider the personality development aspects of the students, which are the crucial aspects in their career planning, and also in the formation of university image and ranking. Recently, there has been a rising interest in international education, as many students travel abroad to pursue higher education in developed nations . Several reasons attract students toward international higher education, including international education, as an essential source of their competitive personality grooming. They were followed by providing improved chances of skills with the help of technology-based educational facilities. Along with all the positives, higher education confronts several challenges in its journey toward adopting emerging learning models and meeting dynamic needs , including issues related to educational technology and cultural and socio-political adoption, specifically in the post-COVID era . It is essential to be mindful that advanced-level teaching and learning cannot be translated into a reality without the influx of technology. Specifically, it is essential to nurture the skills demanded by the job market in the 21st century . It is obvious that the people travel to different countries and are more interested in learning the other countries' cultural norms . The government is taking different initiatives to ensure that the students are provided with every kind of facility in their international high-ranked institutes. They must not be discriminated against because of their varied cultural affiliation . Similarly, it is also the responsibility of the people of the host country to be more tolerant toward international students and let them embed themselves into the host nation's culture. Furthermore, Aboramadan suggests that it is also the responsibility of the international students to promptly integrate with the international culture and opt for strategies to develop their academic profile effectively. Likewise, career planning is supposed to be one of the primary motives of every international student, which is why they prefer developing their academic profiles for a better career . The urge for a brilliant professional career forces most aspirants to travel abroad for quality education. Similarly, through innovative quality academic learning, international students reasonably develop their personalities for a better professional career . It is believed that those students who get an education in the international institutes of a high standard have more robust and influential personalities than those who do not have the opportunity to learn in the international institutes . In developed countries, cultural difference is one of the main problems for the international students. It is essential to understand that the students with high cultural adoptive profiles sail through all the technological and socio-economic-political hiccups. However, the students with a dominant mother culture personality face different problems in the way of their cultural adoption . Furthermore, it has been observed that there is a definite shift in international academic institute structure, which has given rise to the unique, innovative educational possibilities to diversify teaching and learning procedures . As such international learning environments have emerged at a rapid pace, they have been termed the innovative learning environments, which hold the potential to engage, motivate, and attract a more significant number of international academic aspirants . It is one of the reasons why the desire to be part of institutes with innovative learning environments is quite prevalent among students interested in pursuing higher education. Moreover, according to Ige et al. , innovative learning behavior is one of the key traits that help people develop their profile by identifying new ways of learning. Students with innovative learning behavior are more substantial and effectively learn things . However, to reach its full potential, it is essential to realize that digital evolution across international higher education has made all stakeholders undergo identifiable changes because of this innovative learning shift. It requires a sufficient adaptation on behalf of students, teachers, and the international institute at large . Consequently, to test the phenomena at hand, this study uses the prism of higher education theory. Therefore, this study aims to understand the role of an innovative learning environment, career planning and socio-cultural adaptation, and difficulties as determinants of higher education institution choice decisions by international students in the post-pandemic era. In pursuit of testing the above-stated relationships, it is imperative to understand that the cultural and social botherations caused by the host countries are some of the primary roadblocks to the success of the international academic institutes. These indicators hinder international students from seeking admission to such institutes . Therefore, this study is designed to understand to what extent of innovative learning environments, career planning, and personality development opportunities lead international students to get an education in the international institutes in the post-pandemic era. Significantly, the theoretical framework of this study has been extracted from recent studies with inconclusive findings. Notably, past studies lack understanding of innovative learning environment, career planning, and socio-cultural adaptation difficulties as determinants of higher education institution choice decisions by international students in the post-pandemic era. Therefore, the framework of this study is designed to provide meaningful information related to the motivation, career planning, and cultural adaptation difficulties in the context of the higher education of the international students in developed and advanced countries. To the researcher, no particular study was conducted to address the relationship between career planning, personality development, cultural adoption, and higher education in international institutes. However, the theoretical implications of this study would address the gap in the literature and emphasize the role of other variables that bother international academic aspirants and institutes interested in having such students on board. Similarly, the practical implications of this study would be helpful for the stakeholders to consider different variables used in the study for managing and improving the behavior and thinking of the international students to integrate with the culture of the host country's people. Furthermore, this study provides significant future directions that are important for future researchers not to repeat the same work but go with an alternative strategy. --- LITERATURE REVIEW AND HYPOTHESIS DEVELOPMENT In this study, the research model is designed on the interpretation of the theory of higher education . The theory of higher education highlights that the students are more concerned and affected by their thought patterns and beliefs, which they establish over time . Therefore, this theory emphasizes higher education management's importance in considering these values and providing a sustainable working environment for the students to learn . Furthermore, the interpretive lens demonstrates that by providing a conducive environment for academic growth, college students will be in a better position to perform in a productive manner . However, during the literature review, it was identified that multiple other factors contribute to the sustainable development of higher education for college students. This study has considered multiple other variables such as innovative learning environment, personality development, career planning, and cultural adoption to understand motivation, career planning, and socio-cultural adaptation difficulties as determinants of higher education institution choice decisions by international students in the post-pandemic era. Also, based on these additions to the body of knowledge, stakeholders across the higher education system would be in a better position to emphasize factors that are more critical for students interested in pursuing international higher education in the post-pandemic era. --- Relationship Between Career Planning, Cultural Adoption, and Personality Development It is essential to understand that carrier planning is one of the prime objectives of international students when they are willing to get admission to international institutes for their higher education . It is also observed that the students of third-world countries are more interested in getting admission across developed nations to groom their personalities . However, according to Martín-García et al. , it is not easy to get admission to an international institute because most institutes are backed by several cultural, political, and social norms, and rules and regulations. Studies have revealed that international students face cultural crises during their academic stay at international educational institutes . International students will likely experience difficulties adapting to their new context . It is hard for the international students to survive in the international institute because, in such kinds of institutes, different cultural and social dimensions challenge the ethical norms, and it is not easy to integrate with the student of other cultures . As such, integration might demand multi-level accommodation ; therefore, it would be fitting to expect that international students would have to go through a challenging, life-changing encounter. Conversely, in America, according to the study by Thaothampitak and Wongsuwatt , the students of different countries are getting an education in the higher institutes, and it is believed that American institutions are suitable for personality development and career development. Besides, it is also essential to consider that international students in American institutes are not treated well because of socio-cultural evil that disturbs the educational process across institutes . Similarly, in Canada, students from different countries are getting an education; however, the cultural variation and different social backgrounds are hurdles in developing their personalities, with no counter strategies available for the issue at hand . Likewise, it is critical to understand that it is not easy for people to accept others from different cultural backgrounds. While, on the contrary, such international institutes have a reasonable extent of cultural diversity among students. Moreover, people from different cultures pursue their academic endeavors together, so it is also the responsibility of the institute's management to apply policies to avoid cultural clashes . --- Innovative Learning Environment Career Planning Cultural Adoption Personality Development --- Higher Education Institution Choice by International Students FIGURE 1 | Research model. In the international institutions of Korea, it is reported that the domestic students are more reluctant toward the international students, and most are biased. They do not treat the international students according to their culture and ethical values . It has also been observed that institutes across Korea arrange cultural classes for students who apply from the third world and Asian countries, to be specific, which is adding to the reluctance of international students to consider Korea for their international academic endeavors . Furthermore, international students willing to be admitted to the international institutes are always interested in the host country's culture. The students believe that the cultural class of the first country would not allow these people to get an education in the right way and would not help them develop their personalities effectively . In this regard, the responsibility of the educational institute is to determine the different kinds of problems that are hurdles in the way of admission of the international students to provide the solution for them that would be refractive for their learning . Most of the time, international students face a different kind of crises in international education. Due to such a crisis, their personality development declines, becoming one of the prime reasons behind negative word of mouth. Importantly, in the era of the pandemic, it is noted that students studying in international institutes have faced different kinds of cultural problems. In the American universities, the Chinese student was blamed for the COVID-19 virus, which supposedly happened because of a political narrative set by one nation against the other . On the contrary, it is also essential to understand that the people who represent the different cultures must believe that they should treat others ethically. Importantly, it is the government's responsibility to provide ethical education to the people and develop students effectively for their better personalities and understanding . Therefore, it is crucial to understand that those international institutes that provide students with proper training and career planning and counseling will be in a better position to make them adopt the host culture. H1. There is a relationship between career planning and cultural adoption. H2. There is a relationship between career planning and personality development. H3. There is a relationship between career planning and higher education. --- Relationship Between Innovative Learning Behavior, Personality Development, and Higher Education People from multiple cultural backgrounds live together in international academic institutes, representing their cultures and seeking education. Besides, it is a trend that international students are getting admission into higher education because they believe that getting higher education from a reputable international institute would develop their personality and career through innovative learning practices . Further, people from different cultural backgrounds seek education from international institutes and become more concerned about the host country's culture and political system, contributing a lot to their personality development and learning . In this regard, it is not only the responsibility of the people of the host country to value and respect the international students but also the responsibility of the people who are getting admission to the international institutes to value the innovative learning practices, culture, and the social-economic system of the host country , while failure to adjust to the technology-based creative atmosphere can be subjected to the apparent disconnect between students' culture, host institutes' culture, and their leadership. Therefore, it is believed that the host nations' mutual trust and mutual respect, and academic and national cultural values of each other help develop better harmony among locals and international students. Importantly, with the help of globalization and different drivers of globalism, it has become easier for the people to understand the culture of the people as trade and technology have ensured easy cultural diffusion . It has helped locals realize the importance of accepting the guest students' cultural differences and adjusting themselves accordingly. In addition, innovative learning behavior is crucial for an average student to adjust to the international education scenario, as it helps them accept the emerging innovative academic and cultural dimensions, which make them acceptably alter their personalities . Likewise, to make this procedural and psychological adjustment by students easier, critical analysis on how such an influx of innovative learning models will benefit students' academic outcomes is unavoidable. Similarly, unquestioned implementation of educational innovations might hinder innovative learning procedural adoption . In addition, in their study , have discussed the impact of an innovative learning environment on students' behavioral outcomes. They have referred to an educational environment as a "blended learning environment, " with a sufficient level of digitalized learning facilities. It was also found that there has been an improvement in students' learning and behavioral outcomes once they get a chance to adapt and adjust in such a blended learning environment. That is why the students in international institutes are more developed in their studies than those who get an education from a domestic institute . In America and the United Kingdom, the educational institutes are providing the opportunity for the international student to get the higher education from the facilitated and well-established institutes. The research and development have been established effectively and creatively, contributing to the students' personality . This way, the trend of getting an international higher education has increased over the past three decades. The students are more interested in getting an education in the international institutes because they are wellinformed about the clear distinction between the students of the national and international institutes . Notably, the students are always willing to develop their personality because they believe personality is constantly changing concepts. With the help of more innovative learning behavior, it would be appropriate for the students to learn things critically . Still, a good contradiction exists on how a technology-based innovative learning environment can help enhance student learning and engagement. Therefore, there is a need for a well-thought influx of innovative learning tools, especially the speedy digitalization of the education system during the COVID-19 pandemic. It has made it imperative for the international students to stay ahead in terms of being flexible to cultural, technological, and social variations they will face . Therefore, it is hypothesized as follows: H4. There is a relationship between an innovative learning environment and personality development. H5. There is a relationship between an innovative learning environment and higher education. H6. There is a relationship between personality development and higher education. --- Personality Development, Cultural Adoption, and Higher Education Personality is another critical component of human behavior and action. It is a fact that every individual has a different set of personality traits, and he is entirely different from the other human being. Personality is one of the subjective approaches to human behavior that helps to grow and provides more of a gift for improving the behavior . In the career development of any individual, the role of personality is critical because it matters a lot when one is the applicant for getting any job . In this way, the students are more conscious of developing their personality and attitude to the advanced level for better jobs in the industrial sector. Significantly, Bhatti et al. noticed that the third-world countries are not appropriately working to improve the students' personalities to the required extent. In this regard, the students of the third-world countries are more interested in traveling abroad and getting an education from an international standard academic institute to develop their personality appropriately . In the past, the tradition of traveling for international education was not common because different cultural and social barriers inhibited the people from getting an education from the international institute for higher education . However, with the development of globalism and global institutes, it has become more accessible for people to get admission to international institutes for education. In this way, the students from different third-world countries and the Asian countries travel to the developed and advanced countries to get an education and develop their personalities according to the modern standard . It is critical to understand that if the students are allowed admission to the international institutes, their personalities will be shaped according to the international employer requirements . It indicates that personality development is one of the critical criteria for shortlisting the academic institute held by students interested in applying to international higher education institutes. Therefore, the international institutes that provide students with facilities to groom their personality as demanded by reputed employers will indeed be preferred by potential students for their higher education. The reputed organization will credit the intellectual personalities because of their personal and professional interactions . Knowing that other people attract people with good personalities and positive attitudes is critical because they are more positive and do not react to their perceived values and norms. However, on the contrary, people with low personalities and the capability to work with high standards are not selfmotivated. They are limited to their personality as they are not getting the opportunity for the best education. In this way, the students from Pakistan, India, and China travel to the international institutes and high-class universities in America and the United Kingdom to seek education and enhance their skills related to research and development . This research and developments are not only necessary for the students for the development of their personality, but also it is critical for the people of different countries because, with the help of these personality characteristics, people are more advanced to get the maximum benefit from the society and the educational institutes. Importantly, it is the responsibility of the stakeholder to consider personality as a unique and distinctive human characteristic and provide the opportunity to boost it to the students and other people of the society . If the opportunity was provided to the people to enhance their personality skills, it would be beneficial for them to get the right skills and develop more strategies for maximum benefit. It also indicates that in developing one's personality, the student willingly agrees to adapt to the culture, which is not the primary culture. Students work to adapt academic, professional, and socially benchmarked cultures to achieve the desired performance outcomes. Therefore, according to Pan et al. , it is also the responsibility of the international institutes' management and board of directors to integrate personality with human life and provide opportunities to the international student to develop their personality to the appropriate level. It is also noted that if the opportunities related to personality development are provided to the students in the international institutes of higher education, the development of human skills would be enhanced, and people would become more competent in their respective fields . Likewise, the students from Japan are more concerned about their personality development when they are getting an education in the educational institutes of western countries. Similarly, the English students in America and the United Kingdom are working to develop their personalities and critical skills with the help of higher education because they have the opportunity to get an education in the well-reputed and well-established institutes in the world . In the same manner, the students from every country must be provided with the opportunity for personality development by the management of the educational institute to grow productively to the advanced level for a more efficient result . Therefore, it is proposed as follows: H7. There is a relationship between personality development and cultural adoption. H8. There is a relationship between cultural adoption and higher education. --- METHODOLOGY Prepare Questionnaire This study is based on the quantitative data the target respondents collected through the survey-based method. It is noted that the survey-based data collection method is the appropriate method as it is time-saving and cost-saving. In this regard, the structured questionnaire was prepared on a five-point Likert scale to collect the data to determine the relationship between different variables presented in the study's theoretical framework. Notably, the scale items in this questionnaire were taken from the creditable earlier studies. The scale items for personality development were taken from the study of Penketh et al. . Similarly, the scale item of innovative learning environment was taken from the study of Rosedi et al. . Moreover, the scale items for cultural adoption were adopted from Hadziabdic et al.'s study, the scale items for higher education were adopted from Scotland , and the scale items for career planning were taken from the study of Presti et al. . In addition, these scale items were reviewed by expert researchers to check their significance and worth for the study. --- Data Collection Process The questionnaire of this study was developed carefully and ensured that the integrated scale items were essential and reliable for collecting the data from the respondents. The respondents of this study were the students of different countries that are getting admissions and getting an education in international institutes across China. Moreover, the data were collected from students of international institutes, and 600 questionnaires were distributed to the respondents in China. In this way, the study's introduction also provided a better understanding of the subject. Similarly, the paid envelopes were also provided to them for the return of the questionnaires. The respondents were welcome to ask any question, and in this regard, they were provided with the researcher's email to get an answer related to the questionnaires. However, the incorrect questionnaires were not considered for the study. Finally, 260 questionnaires were considered for the study to analyze the data for the study's hypotheses. --- FINDINGS This study section has the confirmatory factor analysis results which are presented in Table 1. Confirmatory factor analysis is conducted to determine the values of factor loadings for the scale items of variables used in the study. Significantly, the values of factor loadings for all scale items were not less than 0.40, as recommended by Hair et al. . Furthermore, the scale items used to measure the data are presented in this study section. These scale items were carefully considered to determine the relationship between the hypotheses developed based on the theoretical framework of this study. --- Measurement Model In this study section, AMOS software was used to determine the reliability and validity of the scale items used . The results reveal a clear correlation, reliability, and validity . Furthermore, the composite reliability values were not less than 0.70, as recommended by Henseler et al. . Also, the average variance extracted value was not less than 0.60 in this study, as recommended by Henseler and Fassott . According to the results, there is apparent reliability and validity between the scale items used for each study variable. In addition, the measurement model fit was determined by analyzing and evaluating the root mean square of approximation, absolute fit measures, standardized root mean square residual, comparative fit index, normed fit index, and adjusted goodness of fit . Importantly, all the values were appropriate for the recommended threshold for it. --- Discriminant Validity The discriminant validity was checked using heterotraitmonotrait method to understand the distinction used for each construct of every variable. Significantly, the results reveal that all the values of discriminant validity were not less than 0.90, which Hair et al. recommended for modern studies. Therefore, according to the results, the constructs used for each study variable have apparent discriminant validity. --- Structural Model In this section of the study, the results of the hypotheses tests are presented in Table 4. H1 was tested to check its significance, and according to the results, career planning has a significant effect on cultural adoption , and H1 is accepted. H2 was tested to check its significance, and according to the results, career planning has a significant effect on personality development , and H2 is accepted. H3 was tested to check its significance, and according to the results, career planning significantly affects higher education , and H3 is accepted. H4 was tested to check its significance, and according to the results, an innovative learning environment significantly affects personality development , and H4 is accepted. H5 was tested to check its significance, and according to the results, an innovative learning environment significantly affects higher education , and H5 is accepted. H6 was tested to check its significance, and according to the results, personality development has a significant effect on higher education , and H6 is accepted. H7 was tested to check its significance, and according to the results, personality development has a significant effect on cultural adoption , and H7 is accepted. Lastly, H8 was tested to check its significance, and according to the results, cultural adoption significantly affects higher education , and H8 is accepted. --- DISCUSSION Table 5 shows the Standardized path coefficient with H1,2,3,4,5,6,7,8. The findings of H1, H2, and H3 demonstrate a significant relationship between career planning, cultural adoption, personality development, and higher education. It is essential to understand that international students travel to first-world countries to get higher education because they want to develop their careers successfully. Indeed, according to Scotland , it is suitable for students who are willing to develop their personality and career by getting an education from a world-class university. However, different barriers, such as cultural adoption and social barriers, must be eliminated. In this way, the opportunities should be provided to the students willing to get an education from the international institutes . It is the responsibility of the government and the peacemaker non-government organizations to intervene and modify the cultural awareness of the students and provide them with information to tolerate the culture of the host country . Moreover, it is also understood that for the development of culture and enhancement of regulations related to the culture, more information must be provided to the people to develop them in a productive way for tolerating the culture and the people associated with it. The Chinese students who are getting an education in the universities in the United States are more aware of the cultural clashes, but they tolerate kindness for their more significant benefit . Similarly, cultural awareness of this kind must be provided to the student of the other countries to ensure that they are not rejected. However, they must consider and value the culture of the other community . In this way, creating unity in the cultural understanding would be an excellent opportunity for developing a mutual relationship between the community for progress and productivity. The results of H4 and H5 demonstrate a significant relationship between an innovative learning environment, personality development, and higher education. However, it is noted that the innovative learning environment is critical for international students' learning when they are getting an education in world-class universities. The students of Japan who are getting an education in Australia and the United Kingdom believe that if they are provided with a sustainable and comfortable environment of learning with the security of innovative learning behavior, then it would be more effective for them to develop their ability constructively . The international institutes are responsible for providing opportunities to international students to enhance García et al., 2019). Besides, it is reasonable to understand that the purpose of every student is to get an education from foreign institutes for the development of the personality because this development in personality provides the opportunity for better understanding . Significantly, the appropriate actions must be taken to create an innovative learning environment with the help of effective and innovative teaching methods to improve the student's performance to the advanced level. Notably, more innovation in the learning must be provided to the students as a result. It solves the problem . In this manner, the higher institutes must be responsible for developing innovative learning strategies and improving the students' performance. The results of H6 demonstrate a significant relationship between personality development and higher education. Indeed, the critical motive of any student is to get higher education for the personality development, because until and unless any institution is not providing the opportunity for the personality development of the student, then it would not be reliable for the student to get admission in that institution . Besides, the international institutes hosting international students are more flexible in providing the opportunity for personality development to the students because by providing these opportunities, the institutes are attracting the students . The institutes contributing to the student's personality are more considerable by the international students for the higher education. The results of H7 demonstrate a significant relationship between personality development and cultural adoption. Furthermore, the results of H8 demonstrate a significant relationship between cultural adoption and higher education. In this regard, it is noted that the students willing to get admission to the international institute for higher education are more concerned about their personality development and profile status. Moreover, some students believe that the host country's culture would be challenging for them in their higher education as the people of different cultures are not ready to tolerate the values of the people of the other culture . Importantly, it is the responsibility of the government and international university management to provide suitable facilities to the students for the development of their personality and socio-culture adaptation exposure . Similarly, the understanding of the culture and emotional intelligence must be provided to the society, so the people should not be face to face for the concerned about their cultural values . In addition, it is noted that in the era of globalism, everyone lives in one integrated culture, but the traditional concept of cultures is not eliminated . Therefore, the management must provide reasonable facilities for cultural tolerance to boost the personality of the international students. --- CONCLUSION This study concludes that there is a significant role of personality development, career planning, innovative learning environment, and cultural adoption provided by the higher educational institute in attracting more international students to take admissions. The study indicates that international higher education institutes need to be mindful of the emerging student's requirements and their rising concerns in the post-COVID-19 era. Indeed, international students are getting an education in America and Canada because they believe their profile would be developed if they get an education from high-class institutes. They would learn critical abilities to understand the problem and cope with the problems in an effective way. Therefore, the implications of the study would be significant for the stakeholders to provide the best and most innovative learning environment by eliminating all of the barriers in the way of international students who are getting admission to the world-class universities of the top world countries. Importantly, this study demonstrates that the gap in the literature was identified that had been addressed by developing the research framework that would be useful for future studies to understand the relationship between different variables that are taken to develop the hypotheses of the study. In addition, the study provides significant future directions that are important to consider for future researchers interested in pursuing research in the given domain in the post-COVID times. Moreover, this study highlights that the responsibility of the international students is to integrate with the host country's culture and develop their personality in the innovative learning environment for career planning by getting a higher education. --- IMPLICATIONS Theoretical Implications This study is designed to provide significant theoretical implications related to the admission and education of international students in the well-reputed international institutes of developed countries. It is a fact that every student wants to develop his personality and career by getting an education from credible international institutes because the educational institutes contribute a lot to the development of a file of the students. In this regard, it is crucial to understand that there are different problems related to the culture and tradition of the international students that limit them from participating in activities to getting an education from the international institutes. However, very few studies were conducted to determine the relationship between different cultural factors in getting admission to international institutions in the post-pandemic era. In this way, the study highlights that the students who are willing to get an education from the international institutes must consider the vital role of personality development and career planning because the educational institutes matter a lot while getting a job in the industry. Similarly, the study demonstrates an essential role of cultural adoption in international education because it was not considered by any earliest studies to influence the students' personality in the international institutions for higher education. Importantly, this study highlights that the innovative learning environment is also critical for the students to be understood for getting an education in the international institutes. In this manner, the study provides the relationship between different variables that are taken in the research framework of the study that would be useful for future researchers to determine the relationship between variables related to the higher education of the students in the international institute. --- Practical and Managerial Implications This study also provides significant practical implications that are important to consider for the stakeholders providing international higher education to the students traveling from different countries to pursue their educational degrees. It is essential to understand that the international students are traveling to the developed countries for an education because they believe that getting an education from the developed countries would be beneficial for them to develop their personality and skills for working and getting a job in the reputable departments. However, it is reasonable to note that there are different kinds of challenges posed by increasing competition and the COVID-19 pandemic that international students face in the international scenario because they belong to different cultures. In this way, it is the government's responsibility and the management of the higher institute to regulate human behavior and provide awareness related to the importance of patience required by international students. Notably, the students are traveling to the developed countries to get an education and want to settle there and get professional life in the developed countries. In this way, it is the responsibility of the host country's government to integrate the international students with the local students effectively to provide the best facilities for learning from each other. Moreover, it is the government's responsibility to ensure that the students are not discriminated against based on culture and must be given equal opportunities to get better results for their living standards. In addition, it is the student's responsibility to value the beliefs and norms of the opponent culture. Because if there is no emotional intelligence to determine the cultural changes, it would be difficult for the international students to survive and pursue their education at international universities. --- LIMITATIONS AND FUTURE DIRECTIONS This study aimed to understand motivation, career planning, and socio-cultural adaptation difficulties as determinants of higher education institution choice decisions by international students in the post-pandemic era. Like any other study, the given one is also faced with certain limitations, which can be the source of future direction for other research. Initially, due to time constraints, the study deals with a cross-sectional research design. However, the phenomena can be studied better if data could be collected from students who aspire to get admission to international academic institutes and when they end up with their degree programs. Therefore, the longitudinal research design is suggested for future studies in the given work area. Similarly, the data were collected only from international top-ranked institutes from China, so there can be an issue of generalizability. Therefore, it is suggested that future studies could look into the phenomena from a comparative viewpoint. The literature review observed that multiple other factors contribute to the motivation and career planning for higher education in international institutes. First, future studies must consider the important role of visa policy in getting admission to international institutes. Second, future studies must focus on ethical values' role in international students' problems. Lastly, future studies should focus on government policies' role in taking admission into international institutes, specifically in the postpandemic era. --- DATA AVAILABILITY STATEMENT The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author. --- ETHICS STATEMENT The studies involving human participants were reviewed and approved by the Shanghai Polytechnic University, China. The patients/participants provided their written informed consent to participate in this study. This study was conducted following the Declaration of Helsinki. --- --- Conflict of Interest: The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher's Note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

The world is facing an unprecedented health crisis with the spread of COVID-19 across different corners of the globe. This pandemic has raised more significant concerns about international students' learning environment, personality development, and career planning, particularly in high-ranked institutes in China. Now the question concerning this dilemma is, would the COVID-19 pandemic negatively affect students' education and the country culture where they are bound to seek information and the subject education? Therefore, this study examines the impact of innovative learning environment, career planning, and socio-cultural adaptation-related difficulties faced by international students as determinants of higher education institution choice decisions made by international students in the post-pandemic era. This quantitative study examined international students in high-ranked universities across China. The data from 260 students were collected through a structured questionnaire and analyzed using the AMOS technique. Moreover, it has been observed that the current global health crisis has intensified social inequalities across different international higher education systems. Countries fail to maintain the scale of the innovative international learning environment. The results further indicated that international students are more considerate of innovative learning environments, cultural adoption, career planning, and personality development, specifically after the outbreak of the COVID-19 pandemic, which has drastically affected the global higher education system. Unusually, more than half of the participants wanted to maintain the option of overall distance education after the pandemic. However, apart from this argument, it is appropriate to demand significant changes in post-pandemic education adapted to the post-digital era and to satisfy the concerns and expectations of the students.

Introduction Menopause is a biopsychosocial phenomenon starting at the median age of 51 marking the end of reproductive life for women . It coincides with mid-to-late career stage, a time associated with technically competent leadership . This study focuses on cognitive menopause symptoms defined as declining 'attention, verbal learning, verbal memory, working memory' , caused by chemical changes to the brain during early menopause . Depending on severity of symptoms, women may have difficulty in managing job demands, potentially leading to voluntary or forced exits from employment as highlighted in some recent UK employment 10.20856/jnicec.5108 Journal of the National Institute for Career Education and Counselling tribunals . The Women and Equalities Committee survey Menopause in the Workplace , found cognitive symptoms were experienced by 73% of women and the second most difficult symptom to manage. Therefore, understanding the lived experiences of women transitioning through menopause is important to create a gender-inclusive and inter-generational workforce . The literature review conducted in 2022 found some women are subjected to workplace gendered ageism including sexist comments on appearance, creating pressure to appear more youthful . Working menopausal women are surrounded by negative messages resulting in some women hiding their menopausal identity for fear of being overlooked for opportunities . Hall and Mirvis describe the meanings women attach to identity whilst experiencing menopause at work, as contextual and influenced by gender-based norms expressed by co-workers leading to potentially adverse performance interpretations . Therefore, any negative perceptions of cognitive ability may weaken 'leader emergence' , for fear of negative performance management or redundancy . Overall, the review found meanings women give to menopause in the workplace is an interpretive, complex process based on self-concept and the work environment . Extant research has predominately been conducted through a positivist paradigm seeking to quantify menopausal symptoms . However, positivism does not give meanings to 'feelings, perceptions, and attitudes' . Uncertainty exists around how professional women in leadership positions make sense and attach meaning to cognitive symptoms associated with menopause. Weick's theory of sensemaking offers a conceptual framework to explain how women make sense and attach meaning to their menopause transition in the workplace. Weick's model, can be used to identity how professional women's lived experiences of menopause are influenced by their interactions with others through language and cues. Drawing on Louis's model for sensemaking in transitions, it is possible given the shock that may occur during menopause transition, women have no established network around them to test perceptions and end up using stereotypes existing in society. Potentially this puts their professional identity into question resulting in adverse interpretations of their capability to work . Therefore if menopause triggers a change in a woman's sense of self, it could influence her professional identity. --- Methodology Given the interest in sensemaking, an IPA framework was used to explore participants' lived experiences . This study contributed to the understanding of this phenomena by asking: How do women experiencing cognitive symptoms associated with menopause make sense of their experiences in the workplace? --- Helen Root Journal of the National Institute for Career Education and Counselling --- Table 1. An Interpretive Phenomenological Analysis . This study was granted ethical approval from Birkbeck University in 2022. In accordance with Smith and Nizza five participants were recruited using snowball sampling via a professional women's network . --- Findings and discussion How participants experienced and made sense of cognitive menopause symptoms in the workplace emerged as five interrelated themes , providing an opportunity to understand the impact of menopause on careers. Menopause was an emotive word, holding a negative meaning for participants. To give meaning to their menopause transitions, participants often relied on how they were before the symptoms started, to make sense of the change in cognitive functioning. This had the added impact of highlighting the suddenness of change to their working lives which came as a shock. In common with other IPA studies examining transitions, participants expressed difficulties in integrating symptoms with their self-concept , as 'not feeling myself'. Symptoms were described as 'not normal' making work experiences more challenging validating Louis' sensemaking theory. Findings are discussed with reference to existing literature and illustrated with germane quotations in italics from individual participants. --- Five Group Experiential Themes & Subthemes A SENSE OF LOSS AND FEAR --- A sense of loss and fear The language of burden around menopause is deeply embedded . This was echoed in this study of seemingly successful and confident professionals who upon menopause transition became fearful of losing credibility, describing experiences using language of anguish such as 'terror' and 'panic': People look to me for direction, for answers, for advice, for guidance. I felt totally spaced out…which was really frightening. It just makes you feel vulnerable…It gives you that feeling of quite isolated, fearful, I thought I'm not going to be able to do my job…I was terrified at the point of it happening. --- Helen Root Journal of the National Institute for Career Education and Counselling Evidence was found suggesting systemic embedded negative stereotypes around menopause, the embodiment of which created concerns about being labelled or capability being questioned: You don't want to walk around with a big M on your forehead and labelled as a female going through menopause…Others will see me as less capable. I don't want to identify as menopausal as I don't think it identifies me. Participants experienced liminality during this time of adjustment, struggling let go of their premenopausal self and embrace their new menopause self: Vulnerable. It --- Confidence and control Participants felt menopause was a taboo subject: 'It's easier to say it's my age forgive me, than to say it's my menopause forgive me' . They concealed and controlled their cognitive symptoms attempting to conform to workplace norms, fearful of giving anyone 'ammunition': For women, where they have reached that level, where they are expected to be dynamic, to be attentive, to be switched on…A price comes with that, you don't want to give anybody ammunition to say: 'she's not performing quite right'. Their sensemaking indicated conflict between symptoms experienced and their work persona of 'intelligent' and 'articulate' further challenging self-concept. Fear of stigmatisation culminated in participants becoming withdrawn questioning their value and organisational fit: As a senior leader within the organisation, people expect you to be sharp...to be switched on. That self-confidence, that self-belief you've built up from years of experience, performing at a certain level, when that isn't there, that fundamentally calls into question…am I in the right place? Am I in the right role? Participants displayed strong role commitment yet when their confidence diminished, became disengaged and started to withdraw commitment to the organisation. Building on the study by Jack et al. All participants expressed negative menopausal stereotypes which were incongruous with the ideal worker characteristics they held such as being 'switched on' and 'sharp'. Sensemaking is a social process in organisations where ideal worker schemas are typically forceful and decisive. Women experiencing cognitive symptoms may feel their identity no longer fits that schema and choose to withdraw . --- Professional identity Professional and nonwork identities are connected dimensions of employability . Therefore, if cognitive menopause symptoms trigger a change in an individual's sense of self, it could influence their professional identity. This study builds on Steffan's research exploring how menopausal women construct work identity. Participants put great value on consistency of performance and intellectual capacity which was tied to their image of a successful midlife career. Unpredictable symptoms created a fear of reputational damage ultimately challenging their self-concept. You don't want anyone feeling sorry for you or feeling pitiful. You don't want to be pitied… I don't want to feel like I am coming across as a menopausal mess because I'm very conscious how to portray myself in a professional setting. Concerns about others' perceptions together with their own thoughts of being a 'professional mess,' cumulated in a sense of negative self-identity: They might treat you differently. They might think differently of you, especially males… You have to look a certain way, like you in control. Like you know what you're doing. Winterich and Umberson found how workplace colleagues define menopause is socio-culturally specific, shaping how women put meaning to menopause impacting their engagement and career choices : I want to be respected so the thought of people losing respect for you because you're not as sharp or as switched on as you've been previously, or your star has dimmed… that would have made me feel deeply, deeply unhappy, deeply unhappy. Negative socially constructed discourses of menopause seep into workplaces not only through the wider socio-economic context, but also through the psychosocial characteristic of organisational environments, where gender inequality is built into employment structures partly through workplace interactions . Parallels can be made with maternity leave returners who think others will view them differently . Helen --- Disclosure The sensemaking process was seemingly environmentally contingent as participants acknowledged the competitiveness in 'pressured', 'vicious', and 'hostile' organisational environments. Direct reporting lines impeded disclosure decisions with particular concern that revealing symptoms might lead to loss of reputation or stigmatisation. Managers were depicted as 'awkward' indicating disclosure decisionmaking was contextual and relational, dependent on how they felt others would judge them . Perceived unsupportive male dominated environments created disclosure barriers: I report to a male. There's absolutely no way on this earth I would have a conversation with him. He would look at me and run away. It's a bit dog-eat-dog… He's a classic male driver just bang, bang, bang. Wants to control everything…no time to hang around…bam, bam, bam, on to the next thing. Some organisations had launched menopause policies, yet there was little faith in policies per se being a mechanism to improve the work environment. Participants felt that changing working patterns might reveal their midlife status and lead to negative career consequences: 'To work flexible hours in senior roles the reason becomes very blatant' . This study adds to the Fawcett survey, which found disclosure was lowest for women in senior leadership roles. Where workplace menopause dialogue existed, language and symbols became integral to participants' sense-making. Participants felt patronised by younger women: 'it was like, oh, bless you'. The O'Neil & Bilimoria three phase model adds to this understanding by finding women's sense of self being driven by relationships. However, fear of disclosure went beyond environmental perception, mostly there was a sense nothing could be done to support them, thus reinforcing feelings of isolation . --- Helen Root Journal of the National Institute for Career Education and Counselling --- Impact at work and on career Participants described considerable challenges maintaining performance levels whilst experiencing symptoms that were often described as being incompatible with the organisations' leadership schema. Participants used assertive language: 'killer', 'ammunition', 'attack' signalling embodiment of the hyper-masculine norms of the organisation . All participants had high work autonomy, yet feared cognitive changes being identified as a performance issue. Participants focused on working longer hours keeping up with job demands to minimise perceived underperformance and protect their reputation, yet there was little sense of work-life conflict in narratives: I would try and read the material in advance to try and get the words and their phraseology into my mind. Behind the scenes I was endlessly checking things...never confident what something was good enough which isn't really me, working longer days…taking more time in the evenings to prepare things than I would have done. This concurs with ideal worker theory where women 'privilege work' over homelife to fit in . Participants often felt 'disarmed' by 'intellectual fogginess'. This sometimes lead to a reticence when taking on new projects: Almost a weariness, that's going to be difficult, a kind of fogginess, intellectual fogginess, needing to be able to do that quickly because you're forming judgements…not being as snappy, it was almost a weariness whereas normally it would be great, get in. As professional women their self-concept of intellectuals became threatened as 'words escaped' them leading to negative self-perception . High-stake psychosocial factors including client meetings and presentations were coupled with feelings of 'incompetence' creating inconsistent self-narratives : I would regularly forget keywords in presentations, often even the subject of the presentation, the word would escape me. I started to lose confidence…it kept happening. The words would escape me. Topics I delivered regularly would dilute, just disappear…just swimming before my eyes…I seem to have lost some of my antennae. Associations with incompetence in the workplace signify a non-inclusive environment ultimately harming women's careers . However, while not disclosing the cause, masking symptoms for fear of repercussions might have stopped managers offering support. Whilst the extent symptoms impacted participants' careers is not certain, it is worth noting all experienced a career transition to some degree during the first year of menopause . This study concurs with the Sullivan et al. review of Supers' career stage model which recognises that a personal difficulty leading to loss of --- Helen Root Journal of the National Institute for Career Education and Counselling confidence could account for changing career direction, feelings of helplessness, and decisions to resign : Is it time for me to move on? Should I stand back and sit in the wings? Whereas before I would have been super focused and excited…Suddenly I feel risk averse, before I would have pushed myself forward…now I'm grappling, do I stay in my comfortable role? Factors driving career transitions come from multiple directions, are socially constructed, and alter over time . Therefore, menopause may have been a catalyst for change for participants, highlighting the importance of social construction in careers at a stage when women are often moving into senior positions . Attempts to conceal symptoms through withdrawing from opportunities could become a barrier to progression , leading to indirect costs for women by not applying for a promotion or reducing hours. Only one participant disclosed her menopause status to her manager and was later made redundant. Whilst she did not feel the two events were connected at the time, her sensemaking was ongoing as she reflected she was replaced by: 'Younger fresher meat…I do wonder if that could just be coincidental' . --- Implications for organisations Whilst formal menopause communications are useful to set the tone within organisations, building on the Hardy et al. study, women's openness about support needed, is unlikely to be tied to an organisation's menopause awareness rhetoric but influenced by the systemic culture. Making menopause a major focus of attention, might conversely result in disempowerment through marginalisation , thus rendering workplace interventions ineffective. Given the relational nature of how women manage careers , this study suggests encouraging informal mentoring to support psychosocial needs could lead to greater career satisfaction . Organisations have an opportunity to train managers on how to have supportive career discussions to promote self-insight throughout the employee life cycle. Through developing an understanding of women's changing needs it is possible to foster a culture of inclusion . In particular, understanding the change in cognitive functioning that some women experience as an early part of menopause may facilitate open ended career path planning ahead of symptoms occurring , possibly increasing employee engagement . Thus, the normalisation of menopause conversations in the workplace, in conjunction with educating managers on the internalised fears many women experience in order to create empathy and reduce barriers to disclosure, may support the retention of midlife talent . --- Helen Root Journal of the National Institute for Career Education and Counselling --- Implications for career practitioners The findings have implications for career professionals when considering the intersection of age and gender in the workplace. Women with successful careers based on intellect, may find their self-esteem and confidence impacted when their professional identity is threatened. Using tools such as a family genogram to analyse social influences, as well as Schein's model of organisational culture to explore workplace environments may support sensemaking around internalised menopause stigma . Unpredictable cognitive menopause symptoms can be connected to decreased self-efficacy and confidence . Therefore, using career construction theory to bring understanding of different life roles may enable clients to build confidence and understand their menopausal self . Career practitioners may consider using Nicolson's transition model , to understand how symptoms impact confidence and professional identity throughout the menopause transition. This study's findings support Wright who found women with cognitive symptoms may experience performance issues where there is an expectation they will have immediate recall of data. Considering menopause often coincides with women taking on more responsibility as they transition into more senior roles , identifying effective coping strategies is important e.g. job crafting to ensure midlife women thrive at work. Attempts to conceal symptoms by withdrawing from opportunities could have unintended consequences and become a barrier to achieving career goals . --- Limitations and future research Whilst the researcher did not explore evidence of contextual factors occurring in participants' lives, menopause intersects with other life stage events potentially accounting for the participants' sensemaking . The experiential themes identified raise an opportunity for further research on different employment groups and ethnicities to further understand the impact of cognitive menopause symptoms on careers. --- Conclusion Change in cognitive functioning such as memory loss during menopause is under researched yet important to understand to reduce stigma surrounding menopause as part of creating an inclusive, multigenerational labour market. By adhering to IPA ideographical principles, the design of this study offers a deep understanding of how professional women experience and make sense of cognitive symptoms associated with menopause. Their sensemaking centred around a desire to maintain reputation and professional identity associated with intellectual capacity. A sense of loss pervaded the participants' language and went to the heart of sensemaking: 'Who am I?' Helen Root

More women than ever before are working during the menopause transition, yet studying menopause from a career perspective is in its infancy. This study explored how women reporting cognitive menopause symptoms make sense of their experiences in the workplace by linking participants narratives, to the social construction of menopause. Interpretive phenomenological analysis (IPA) was used to reveal how self-concept can be called into question thus impacting professional identity and career decisions.

INTRODUCTION Maternal and child health is considered to be one of the key development indicators of any country. 1 Over several decades, improvements in maternal deaths around childbirth have been quite moderate in low-and middleincome countries leading to the MCH strategy as a global campaign to improve maternal health. 2 The reduction of maternal and child mortality as well as morbidity remained at the center of successive family welfare programs implemented in India through the Government of India, various state governments, and partners including international organizations and civil society platforms; however, India still bears an unacceptable burden of maternal and infant mortality. 3,4 Evidence shows that institutional delivery reduces the risk of neonatal mortality by 29 percent in LMICs; it also reduces stillbirth and perinatal mortality as well as maternal mortality. [5][6][7][8][9] Therefore, including the international organization; the national and state government of India promoting various scheme and programs to encourage women for institutional delivery to ensure safe birth. 10 Similarly, efforts have been made in India to encourage families to change their health-seeking behaviors so that the majority of underprivileged families can be mobilized for institutional delivery in public health institutions. The demand side financing scheme, Janani Suraksha Yojana , was launched in 2005 by the National Rural Health Mission of India, which also included cash incentives for community health workers accredited social health activist . In addition, in order to strengthen the supply side, Janani Sishu Suraksha Karyakram was designed as an entitlement scheme for pregnant women and newborns in 2011. 11 The World Health Organization initiative to improve the standard of care given to pregnant women during childbirth is as critical as providing clinical care to achieve the desired human-centred outcomes. 12 Access to health care facilities may not, however, guarantee good quality of care. 13 Across the world, disrespectful and unworthy care is prevalent in many facility settings, especially for underprivileged populations which violates their rights to create a significant obstacle to seeking healthcare and discourage them to favor institutional delivery. 13 However, the literature revealed that there is little evidence in India regarding respectful maternity care . Therefore, the purpose of this study was to explore the experiences of ASHAs on RMC in Odisha, India. --- Rationale Disrespect and abuse is a concept closely related to obstetric violence. Also, respectful maternity care is not only a crucial component of quality of care; it is a human right. There have been many anecdotal reports which depicts pregnant women seeking maternal health services receive discrimination, abandonment, disrespect and abuse in a health care facility. In the Indian context, there is an urgent need to execute specific research which will explore and highlight the community peoples' knowledge and perception regrading disrespect and abuse not only at the facility level, but also at the community level. ASHA is the grassroot level worker which connects community as well as the health system. ASHA could be a helping-hand in spreading awareness among the community related to disrespect and abuse, which enrich the concept of respectful maternity care among the childbearing mothers in a community. Hence, it is important to know the perception of ASHA towards respectful care in the facilities and her role in providing knowledge about respectful maternity care in the lens of human rights. --- METHODS --- Design and settings A qualitative exploratory study was conducted in Odisha, India. Three districts were chosen from the 30 districts of the State, with one district from each of the three revenue zones of the State. Total of 24 In-depth interviews were conducted among ASHAs eight from each district. All of these participants were actively involved in the provision of MCH services, motivating and accompanying women for institutional delivery. --- Inclusion and exclusion criteria Participants were recruited by authors who belonged to the study settings . Providers were, on average, 30 years old ranging from 23-38 years, and everyone had working experience for more than three years. All participants belonged to rural areas. Those who are not willing to participate were excluded from the study. --- Ethical consideration The names of the districts were not maintained in order to protect confidentiality. A brief overview of the study, the intent, and their position over the research study was provided to the participants prior to participation and their written consent was obtained. The interview was conducted at the home of the participants according to their convenience. --- Data collection and analysis The data were collected using semi-structured face-to-face interviews between March to May 2019. The interview guide was developed in the local language in this case 'Odia'. The interview guide contained questions about the participants' understanding of RMC and their perspectives as well. Participants were asked about their involvement as a birth companion, the facility's situation, and the health care provider's behavior. In addition, they were questioned about their opinion on addressing disrespect and violence at the facility level. All the IDIs were recorded digitally. The interview lasted between 30 and 65 minutes, with an average length of 45 minutes. The interviews recorded were transcribed and translated into English. The data were analyzed using content analysis methods. 14 --- Interview guide The interview guide was developed in English and later translated into Odiya by the researcher. The interview guide was at first piloted and pre-tested for comprehensibility with a sample of five ASHAs at Khurdha. The interview guide contained questions on participants' perceptions and current opportunities and practices on respectful maternity care. To address our first research aim, participants were asked about their perception towards respectful maternity care, how they assess child-bearing mothers' needs and expectations prior to the delivery in a hospital, and their job responsibilities towards a delivery mother. They were also asked directly about their health promotion activities in terms of respectful maternity care at the village level. In addition, our second research aim was to explore ASHA's respectful maternity care practice opportunities, specifically in the view of promoting institutional delivery and their role in delivering respectful care. The researcher also asked for their suggestions or recommendations regarding disrespect and abuse or practicing respectful care at the individual level. --- RESULTS Two main themes emerged: Community health workers' experiences and perception towards disrespectful care, and Factors contributing to irrational care. The findings are presented under each major theme/category with quotes from the participants. --- Theme 1: Community health workers' experiences and perception towards disrespectful care Category 1: Disrespect towards the childbearing women: A number of experiences have been perceived by ASHAs regarding the behavior of healthcare providers. Although some said about the warm and gentle actions of doctors and nurses, others shared their negative encounters. The most common expression of the study participants was in reference to medical negligence, misbehavior, and bribery. In addition, inadequate contact to support mothers who have discomfort during work has been rooted in maternity care practices. "The senior gynecologist is really nice. He is very polite, and he treats us and pregnant women as members of his family, however, the nurse expects money from the family of delivery women" . In addition, discrimination in maternal health services was expressed by ASHAs, which identified social determinants such as economic status, and caste as factors affecting mothers' accessibility and experience in health services. For example, a poor mother from a lower social caste was more likely to be discriminated against and exploited when receiving maternal health care in public health facilities. "There are two-three nurses who only tend to work with cases of higher castes. The staff nurse is very reluctant to deal with cases coming from the scheduled tribe community. We have no issues with mothers who have a good financial background. Mistreatment often happens with poor ladies-they have been unable to provide bribe" . Participants also established the notion of the insensitive and coercive essence of maternal care given at health facilities. The abuses have been encountered both verbally and physically, often both. During the intrapartum period, the mothers were scolded, eve-teased, and slapped. Another dimension of disrespect witnessed by ASHAs was during the episiotomy process. In a few health facilities, episiotomy is performed by service providers without the consent of the mother or accompanying person. If questions raised by the mother or the accompanying person, the health service providers threatened to refer them to another hospital or insist on visiting private hospitals. "After delivery, Rama shared her terrible experience of being scolded during delivery; you didn't have any pain during sexual intercourse, and now you're behaving like dying out of labor pain " . Category 2: Disrespect with accompanying persons: Lack of information related to dignified care; the bureaucratic nature of the health care system was the key reason why ASHAs were scolded by healthcare providers. Few ASHAs said they had to establish a good relationship with their ANMs and other health professionals to prevent mistreatment. For example, most of the time, they had to do the job of an attendant, such as buying coffee or tea. "Sometimes, after birth, the mother was left without a cloth. I wrapped her up when I was allowed to enter the room. We were asked to clean the floor and the bed; if we refused, my patients would be referred to a private nursing home, where high out-of-pocket expenses" . The understanding of the ASHAs was that the presence of the relatives ensured a loving care of the child-bearing mother as they could stay close to the mother and the newborn during and after birth. Although few ASHAs have been reported, most healthcare providers have not allowed anyone inside the labour room. Often, if the relatives inquired about the women, most of the time they were verbally abused. The lack of information related to women during a crucial time was also a form of disrespect usually experienced by relatives in health facilities. One ASHA reported that the husband of a child-bearing woman faced disrespect and chose not to use the services in the future. "Just close your mouth and stay out there. Don't question us again and again. If you inquire another time, just take your wife to another hospital" . Category 3: Birth preparedness and complication readiness and case priority: When asked to identify the participants as to their responsibility and obligation towards a child-bearing woman, few participants reported that Birth Preparedness and Complication Readiness often contributes to mistreatment by health care providers. The two important components of the BPCR are the identification of the birth companion and the organization of the mode of transport. Few ASHAs reported on the various challenges they faced while taking a child-bearing woman to the facility, specifically in terms of transportation. In the event of an emergency, sometimes the ambulance could not reach a time that restricts mothers not only from providing maternal health services, but also ended up facing disrespectful behavior on the part of health providers. Although few ASHAs acknowledged their mistake in this situation, few blamed the management of the health care system. Some participants have clarified the adverse situation they had to face from both the community and the health system, which sometimes resulted in an uncomfortable state. "Listen to" was just the term, no one really tried to grasp it. As a result, they felt devoid. In resource-limited facilities, eight women had to be taken care of simultaneously most of the time by one health care provider, and at that point, emergency and lifesaving treatment had to be given priority over comfort to a woman. Few participants also made it clear that caste, socio-economic status, and multiparity could lead to discrimination and abusive behavior on the part of healthcare providers. "The staff usually focus on the only high-risk cases. If health providers treat everyone equally and provide equal services, then no one will feel superior and inferior" . --- Theme 2: Factors contributing to irrational care Category 1: Institutional factors: According to the participants, many of the facilities have been underequipped, which has always compromised patient safety and quality of care. The scarcity of human resources and workloads eventually led to abusive behavior and to the mistreatment of patients. In some cases, doctors suggest referrals to other private health facilities from which commissions are received. "Most of the cases were referred to the nearest private hospital. The doctor does this, knowingly, in order to get extra income from there" . Lack of transparency was also a factor leading to disrespect and violence at the facility level. ASHAs clarified that no one at the facility level would like to take responsibility for offering any potential solution to the actions of the providers. They also indicated that if anyone could track and supervise them and inform them about the attitudes they exhibit to the patients. "I couldn't understand whom to approach about the problem at the hospital. Nobody is going to listen" . Category 2: Non-compliance with guidelines and ineffective enforcement mechanisms While numerous policies have been introduced in India, which depict health rights, the definition and theory have remained abstract and their implementation has been neglected in public health facilities. In addition, participants had no clear knowledge of health policies and regulations, suggested developing possible policies, strengthening the care delivery system or strictly monitoring existing regulations, so that mothers would be able to receive respectful care during their maternity period. Taking feedback from and accompanying pregnant women could be an effective strategy for improving the delivery of quality maternal care. The respondents suggested for few rules and regulations at the health facilities which should be legitimized and followed strictly by every single resource person. The implementation of a grievance redressal mechanism would be an appropriate solution to improve the quality of care in the form of respectful and dignified care. The respondents suggested a few rules and regulations for health facilities that should be legitimized and strictly followed by every single resource person. Implementation of the grievance redress mechanism would be an appropriate solution to improve the quality of care in the form of respectful and dignified care. "Feedback must be received from the mother or family members on their experience of service. Then only the doctors and nurses will be afraid of being abused" . Category 3: The hierarchical structure of the health system: It has been understood that breaches of the concept of respectful and dignified care have always been the product of professional hierarchical systems, power relationships, education and cultural attitudes. Responses of the participants showed that the overpowering perception of health care providers often transforms to shame and contempt because of the hierarchical nature of health care providers. "Education and status play an important role. They are the doctors and the nurses. How much we are going to try and convince and make patients and families understand, they are going to say we are just a nurse. When the patients arrive, they must listen to the doctor" . --- DISCUSSION Community health workers explained that the type of abusive behavior of the child-bearing women was significantly different. Verbal abuse was one of the most common and often used by healthcare providers toward community health workers. The consequences of such abusive behavior hinder the effective performance of their role in the facility. Although many community health workers did not have sound knowledge of RMC, the study highlighted major gaps in the behavior and attitude of health care providers at the facility level. The use of institutional health services for delivery reduced the risk of complications between the mother and the newborn baby. Various studies have shown that institutional delivery reduces the risk of maternal and newborn mortality and reduces stillbirth. 7 A comparative analysis performed by Chinkhumbaet.al revealed that perinatal mortality was 21 percent higher for home delivery compared to facility delivery. 15 A substantial decrease in maternal, fetal and neonatal mortality was associated not only with institutional delivery but also with the involvement of professional workers. 16 Similarly, the study found that, compared to women with intrapartum complications at home, the incidence of perinatal mortality among women with intrapartum complications was 43 per cent higher for women who performed at a public health facility. 17 Another study also explained that women living in areas near facilities offering comprehensive emergency obstetric care , emergency neonatal care, or high-quality routine care, or facilities with satisfactory skills found a lower risk of intrapartum mortality. 18 The Government has implemented a variety of schemes to promote institutional delivery in public health facilities. The drivers of this shift from home to institutional delivery include the social pressure of the Accredited Social Health Activist to deliver in a health facility and individual perception of the importance of safe and easy delivery, most likely an expression of the new social norm. In addition, the incentive was a significant factor in many women's decisions to be taken at a health facility. 19 Usually, women are likely to go to health facilities due to knowledge of: increased provision and birth-preparedness education; prior delivery of health facilities; and improved quality and usability of facilities in recent years. 20 Women preferred delivery to healthcare facilities to better manage complications. 21 Furthermore, the various maternal schemes implemented to increase institutional delivery have the potential to reduce maternal and neonatal morbidity and mortality, along with ensuring maternal health equity in India. 22 Various factors are associated in the search for maternal health services from a healthcare facility. The JSY cash incentive scheme played a smaller role as an enabling factor due to higher opportunity costs in the use of healthcare facilities compared to home delivery. 23 Other emerging factors that deter the process of seeking maternity services are the mistreatment and abusive behavior of healthcare providers, which has been identified not only in Indian public health facilities but also worldwide. [24][25][26][27][28] Especially, when planning and implementing maternal healthcare, a right-based approach must be developed and implemented. WHO describes such an approach as one in which human rights norms and values are integrated into policy planning, execution, supervision and assessment. Such values and ideals include equality, respecting vulnerable population needs, fairness to health services and protection from discrimination. This study will contribute to the existing knowledge regarding the quality-of-service delivery along with the abusive treatment among childbearing women. Policymakers should consider these findings while planning maternal health-related policies. --- Limitations A major limitation of this study is its reliance on Health workers' self-reports. Another limitation of the study relates to the generalizability of findings, as these may be limited to the experience of health workers in Odisha for the women who deliver at public health facilities. --- CONCLUSION Despite the lack of knowledge and training related to RMC, participants claimed the disrespectful behavior of healthcare providers towards the child-bearing women and the accompanying person. The findings of this research study have important implications for the promotion of maternal health and well-being, indicating the need for significantly increased exposure to this issue. Mistreatment and abusive behaviour, as important as the quality of health services or geographical constraints, are essential dissuasive for obtaining care. The violation of women's health again threatens current attempts to improve the quality of birth attendance. Respectful and dignified care, along with positive attitudes among healthcare providers, will contribute to improved maternal and neonatal health outcomes. --- Funding: No funding sources Conflict of interest: None declared Ethical approval: The study was approved by the Institutional Ethics Committee

Background: Every woman deserves respectful maternity care, throughout her journey to motherhood. However, disrespectful maternity care is prevalent in various settings. It has an effect on the utilization of services. It can be more explored from the witness of maternity. The aim of this study was to explore the experience of accredited social health activists on respectful maternity care in Odisha, India. Methods: A qualitative exploratory study was conducted among 24 ASHAs with more than two years of experience to gain a deeper understanding of the phenomenon. This study was conducted in three distinct Odisha districts, India. Results: Two main themes emerged: Community health workers' experiences and perception towards disrespectful care, and Factors contributing to irrational care. Participants explained that verbal abuse was the most common use of health care providers. The consequences of such abusive behavior hinder the effective and efficient performance of their role, especially when it comes to their role in the facility. The study highlighted major gaps in the behavior and attitudes of healthcare providers at the facility level. Conclusions: Despite the lack of knowledge and training related to RMC, ASHAs acknowledged the abusive and disrespectful behavior of health care providers not only towards the child-bearing women but also towards the accompanying person, i.e., ASHA or a member of the family. Such mistreatment often acts as a barrier to the use of public health services, such as the institutional delivery of child-bearing mothers. A need for orientation and training on RCM among healthcare professionals, along with appropriate monitoring of implementation.

Introduction Recently, numerous studies have significantly enhanced the chances of theorizing about Brazilian social thought, showcasing the breadth of topics and approaches from the perspective of the establishment of this field of study , the organization and actions of intellectuals , interpretative research lines , the relationship between intellectuals, culture, and politics , the intellectual repertoires available , the collective actions of intellectuals and their interactions with social movements , and ideas and their contextualization . These perspectives have paved the way for investigations into the connections between social and sociological theory and Brazilian social thought, extending the possibility of sociological theorization beyond the confines of the North Atlantic . Peripheral scientific contexts and interconnected sociologies have emerged as crucial elements in supporting alternative explanations of Modernity. By transcending their national contexts, these perspectives contribute to the construction of contemporary sociological theory on global themes such as modernism, modernization, and different manifestations of Modernity . In a certain way, these peripheral modern experiments challenge the Eurocentrism inherent in sociological explanations and propose new approaches to understanding the production, dissemination, and assimilation of ideas and cultural products. Furthermore, they allow for a reformulation of social theory regarding the motivations behind social actions and, thus, a reevaluation of the meanings and significance attributed to social actors throughout the historical development of these regions. The development of national and regional sociologies, particularly in peripheral contexts, has brought attention to these specificities as unique characteristics of peripheral modern experimentation . Contrasting and comparing the trajectories and historical developments of peripheral areas with central regions has played a crucial role in interpreting these places1 . In the case of Brazil, the flourishing of essayism in the 1920 and 1930s was instrumental in characterizing the process of national modernization. It stands as one of the most prolific expressions of local modernism . This particular interpretation of Brazil reveals the essential factors that contributed to the formation of an imagined community , the bureaucratization of public administration, the establishment of solidarities and social dominance, and the shaping of hierarchical subjectivities . These elements were pivotal in mobilizing the social actors who played a fundamental role in Brazil's historical process, providing a foundation for understanding the rationale and meanings behind their actions, as well as the spaces in which these actions unfolded. Through its exploration of the relationship between space and social action, the essayistic interpretation of Brazil has constructed a rich diagnosis of the trajectories of Brazilian modernity. In the first part of this article, we delve into the concept of the modern chronotope and its intricate relationship between space and time. Drawing upon Mikhail Bakhtin's insights, we aim to establish the foundational elements of the chronotope, which encompass temporal and spatial markers and would summarize the actions of characters, pointing out howp figuration is conceptualized within social theory. This exploration encompasses both the construction of a figuration space and the creation of an imaginative cartography. Furthermore, we have delved into the interplay and contrasts arising from studies on space within Brazilian social thought. Our aim is to uncover the processes through which space was constructed, perceived, imagined, and/or experienced, and to establish connections between these spatial imaginaries and contemporary social theory. We place particular emphasis on exploring the physical and symbolic dimensions of these imaginative constructions of space. Lastly, in the concluding sections of the article, we examine the substance of Brazilian essayism during the 1920 and 1930s. Our focus is on elucidating the operative mechanisms that connect figuration as an explanatory factor for social actions of actors with the imaginative cartography. We particularly highlight the contrasting elements within the peripheral trajectories of Modernity and their spatial imaginings. --- Sociological theory and imaginative cartography: trajectories of modernity The utilization of the concept of multiple modernities and its critique of the theory of modernization has prompted a reconsideration of the historical processes that have led different regions to modernity. As noted by Eisenstadt , the notion of homogeneity should be discarded since actual developments in modernizing societies have contradicted the homogenizing assumptions of the Western program of Modernity. Instead, multiple patterns of societal organization emerged, which are undeniably modern but distinct from the Western model, such as European Modernity in this particular instance. 2 The notion of multiple modernities posits that the most effective approach to comprehending the contemporary world and explaining the history of Modernity would be to perceive it as a continuous process of formation and reformation of various cultural frameworks. National or regional cases, with their distinctive characteristics, can be seen as part of a broader global modernity or world-system, as proposed by Wallerstein . They would be characterized by a unified time-space framework in which a division of labor facilitates the material reproduction of the world. Its spatial scope, determined by its material-economic foundation, encompasses political entities and supports diverse cultural systems. As process by the capitalist world-economy, the division of labor and unequal distribution of surplus would give rise to central and peripheral activities based on the capacity of capital and state alliances to absorb surplus within various commercial chains, utilizing economic and non-economic means. Expanding on our argument, if we were to critique the homogenization and Western-centric view of Modernity, we would have to consider how these national and regional examples made us to think the heterogeneities that emerge from the unique developments of each sociology within the context of nationstate formation, market economy, and the formation of social classes. Furthermore, it would prompt us to examine how these national and regional cases relate to the broader modern world-system in which they exist. The analytical reconfiguration of trajectories towards Modernity has challenged the Eurocentrism inherent in classical and contemporary sociological perspectives, thereby questioning the universal validity of categories traditionally regarded as unambiguous markers of Modernity. This reconfiguration also scrutinizes the replication or imitation of modern patterns from central societies within different space-time contexts, shedding light on power asymmetries that underpin normative and prescriptive projections of these central societies onto peripheral space-time contexts . Ultimately, these alternative perspectives offer alternatives to the hegemonic notion of Modernity and propose non-modular trajectories within it . Therefore, we can acknowledge the analytical existence of multiple trajectories within the modern chronotope, whether viewed through the lens of multiple modernities , the world-system , global modernity , or hegemonic Modernity . This interpretive and constructive exercise aligns with the proliferation of theories concerning the social and political aspects of Brazilian thought, which stem from these non-hegemonic paths of Modernity. Moreover, it leads to the establishment of two fundamental elements in sociological theory: space and time. These elements form the basis of the analytical category known as the chronotope. Initially, we refer to Bakhtin's definition, which characterizes the chronotope as the essential interplay between time and spatial relationships artistically assimilated within literature. According to the Russian author, the key concept of chronotope lies in the unification of time and space, with its literary function being the organization of narrative events through the condensation and materialization of time markers-such as human lifespan, historical time, and social time-within specific spatial contexts. When examined through the lenses of historiography and social theory, the perspective of chronotope enables a meaningful debate if the time markers were encapsulated by the actions of plot characters, their figuration, and the formation of figurative space, referred to as imaginative cartography. In other words, as we bridge the gap between literary criticism and the formation of sociological theory, our aim is to emphasize time markers that allow for the systematization of non-hegemonic trajectories of Modernity present within Brazilian social and political thought. These factors present a dual challenge to the chronotope: figuration and imaginative cartography. It is worth noting that, in his exploration of the concept of 'formation' present in Brazilian essayism, Bernardo Ricupero draws upon Bakhtin's ideas, even with a quick look, to develop his arguments centered around the syntagma of ideas out of place, as proposed by Roberto Schwarz . Ricupero rejects the notion that the concept of chronotope simply implies a standardizing aspect or recurring theme in every work or author within a particular context. --- Weaving and contrastivity: imaginative cartography in the brazilian social thought Numerous studies have drawn attention to the theme of territory and space within the sociological imagination of Brazil's scholars . Oliveira emphasizes the significance of territorial conquest in shaping national identity while discussing the evolving meanings associated with the term 'sertão' in Brazilian social thought. This exploration extends to the creation of the myth of hinterland and the notion of borders stemming from the movements of the bandeiras , leading to an analysis of the bandeirantes and their mythical function in organizing the symbolic world and constructing an interpretation of the country. Candice Souza draws attention to the constructed versions and visions of Brazil's rural areas. Through an examination of various interpretations of Brazil that contribute to a reflection on national singularity within the spatial dimension, the author explores the geographical imaginary depicted in discourses surrounding the nation-building process and the formation of Brazilian identity. These native representations of nationality gave rise to a geographic nation, a discursive invention wherein nationality is equated with spatial terms. The country's fragmented unity, territorial discontinuity, spatial imbalance, heterogeneity, and the contrasting notions of hinterland and coast become recurring themes in the renowned narratives of Euclides da Cunha , Cassiano Ricardo , Oliveira Vianna , Nelson Werneck Sodré , and Nestor Duarte . Similarly, Lima delved into the power and significance of geographical metaphors in shaping representations of a national identity for a country perpetually embroiled in spatial conflicts. By uncovering the portrayals of an identity that is consistently portrayed as incomplete or in need of reconstitution, Lima proceeds to analyze the mindset of modernizing intellectuals, who grapple with the irreducible distances between the numerous 'countries' within Brazil. She highlights the enduring divide and contrasting characteristics of the hinterland and coast, metaphorically fashioned by the country's interpreters. Robert Wegner , on the other hand, explores the connection between tradition and Modernity through an analysis of Sérgio Buarque de Holanda's work, particularly focusing on the theme of borders and the expansion of the Brazilian West from São Paulo. By examining the concept of borders and the relationship between Iberian tradition and modernization, Holanda's works from the 1940 and 1950s discuss the characteristics of Modernity in a Brazilian context and reassess the dual polarities present in his interpretations of the 1930s. He envisions potential combinations between traditionalism and modernization, civility and cordiality, idleness and work, as well as Americanism and Iberian influences. The recurrent nature of this theme prompts an analysis aimed at establishing markers for a reconstitution of the subject within Brazilian social thought, specifically within peripheral social theory. João Marcelo Maia's work is relevant in this context. According to him, there is a correlation between space and sociability in the interpretation of Brazil, which supports a dual dimension. Firstly, there is the production and analysis of space as an independent variable in explaining habits and customs, encompassing physical space as the backdrop of civilization. Secondly, there is a conception that associates space with images and allegories closely tied to forms of sociability and civilizing organization. Lastly, Werneck Vianna delves into the territorialism of the Iberian elites in the development of Brazil, specifically in the formation of interests that would clash with the pace of the passive Brazilian revolution. This revolution, characterized by its transformative nature, serves as the driving force behind the actions of these characters and their aspirations over time, intertwining elements of tradition and rupture. It is within this framework that the political elites of the nation-state prioritize political reason above other rationalities, resulting in the preservation and expansion of territory and the exertion of control over the population. Based on the insights and perspectives provided by scholars of Brazilian social thought, the theme of space can be understood through two complementary aspects. Firstly, there is an ordering of physical environments and social categorizations, presenting it as the stage where the civilizing process unfolds. Secondly, these physical environments serve as a foundation for the creation of images and symbols that imbue social experiences with meaning. It is through this fundamental duality that the construction of an imaginative cartography of Brazilian social thought takes shape, considering both the physical and symbolic dimensions within the framework of the constitutive imaginary of interpretation . In line with this perspective, it becomes necessary to delve into the complex conceptualizations and interrelationships between space and territory. As Milton Santos suggests, "[…] as a starting point, we propose that space be defined as an inseparable combination of systems of objects and systems of actions". In its entirety, this definition encompasses the process through which the natural space is appropriated through human intervention, influenced by the dynamic interplay between actions and the environment. This interplay encompasses material and immaterial aspects, encompassing economic, social, cultural, and practical needs. Space not only holds symbolic significance but also serves functional purposes. Understanding space goes beyond the mere recognition that territories consist of objects from different periods. It also involves recognizing that territories are socially constructed and imbued with diverse meanings. As Santos argues, territories have layers of historical significance, with their past manifested in the forms and functions of objects and the natural environment. Moreover, territories are shaped by various cultural layers, reflecting the meanings and values attributed by society to different aspects and portions of the territory. This complexity is evident in the interpretation of landscapes. A rural landscape, for example, can evoke a sense of bucolic connection with nature while simultaneously being seen as archaic or associated with backwardness and ignorance. Conversely, urban environments are often characterized by dynamism and temporal acceleration. Having said that, the construction of an imaginative cartography extends beyond the physical substance of territory or landscape. It encompasses how this substance is interpreted and given meaning by different individuals. This process involves contrasting and evaluating different places, resulting in spatial differentiations in both form and substance. Moreover, the understanding of space is characterized by its referentiality and the contrasting relationships it establishes with other territories or landscapes. The construction of these distinctive images of the territory relies on the power to represent and rank places based on various interests, aspirations, and Acta Scientiarum. Human and Social Sciences, v. 45, e68368, 2023 sentiments that are shaped by the complex web of social relationships and power dynamics inherent in the interpretation. In this sense, the imaginative cartography functions as a network, interweaving social relationships and power dynamics . If space exhibits such characteristics in the construction of this imaginative cartography, then we must further explore the role of figuration in the process of structuring social groups, different forms of sociability, and the motivations and meanings underlying social actions that would fill the ground with density established by the imaginative. --- Essaysm and social figurations: a social action theory From the perspective of social theory, the concept of figuration encompasses the intricate network of interdependent relationships among individuals, which manifest in various ways and at different levels. The collective actions of interdependent individuals give rise to a structure characterized by a multitude of emergent properties. These properties include power dynamics, tensions, class and stratification systems, forms of solidarity, and social hierarchies. According to Norbert Elias ), figuration represents a profound interconnection between subjectivity and social and historical structures. He argues that individual actions cannot be understood in isolation from the social structures that enable or hinder them. Figurations would be forms of relationships that emerge and evolve over time; their alterations and transformations end up shaping both social organization and subjectivities in concerning corruptions. The concept of figuration goes beyond mere technical or narratological description, although it can be seen as an elaborate effect of characterization. A figuration is an interdependent network that is both structuring and structured by the interactions and conflicts arising from power dynamics among groups or individuals fulfilling different roles. Furthermore, the conception of figuration highlights the agency of individuals in shaping historiography, as certain groups exert influence within this interdependent network. Figurations, seen as meaningful social relationships, become more intricate when they intersect with time and space . Space assumes a crucial role as the backdrop for social actions, in the way how time is socially generated , while time encapsulates the collective experiences of social actors. Ultimately, it is the understanding of space as a relational arrangement of beings and objects in the ways in which space ) and time are experienced. Returning to the concept of chronotope, influenced by Bakhtin , space is envisioned through the lens of imaginative cartography, while social action finds expression through figuration. Broadly speaking, figuration and imaginative cartography involve a process of semiotization, where a language is constructed to convey meanings and generate pragmatic effects in the analysis of Brazilian essayism. According to Afrânio Coutinho , the essay is embraced within Brazilian culture not so much as an attempt, but rather as a mode of interpretive study. It becomes the paradigmatic form for historiographical, philosophical, political, and sociological interpretations during the first half of the 20 th century. Therefore, the act of writing transcends the realm of fictionality typically associated with literature. In Brazil, the essay is a genre that defies disciplinary boundaries. In a sense, building upon Coutinho's ideas as presented in Literatura e sociedade, Antonio Candido has approached Brazilian essayism by emphasizing its connection to the tradition of thought and the intersection of fictionality found in literary works with a scientific foundation. The allure of literature would exert a strong influence on the sociological inclination, giving rise to a hybrid genre of essay that merges history with economics, philosophy, or art. This distinctive form of investigation and exploration of Brazil is uniquely Brazilian, and it has produced notable works such as Sílvio Romero's História da literatura brasileira, Euclides da Cunha's Os Sertões, Oliveira Vianna's Populações meridionais do Brasil, Gilberto Freyre's writings, and Sérgio Buarque de Holanda's Raízes do Brasil. It is fair to say that this line of essay-which skillfully combines imagination and observation, science and art-represents the most characteristic and original aspect of Brazilian thought . Regrettably, Candido did not delve into a more systematic reflection on the genre that he himself considered to be "the most characteristic and original aspect of Brazilian thought." Nevertheless, he viewed the essay as a distinctively modernist manifestation, as it interpreted Brazil through a synthesis that allowed for the discovery of authors associated with what is known as the pre-modernist period. The presence of the essay as a defining feature of those years is indisputable. However, the choice of this type of writing represented an expansion of what had been done in the 19 th century, blending a 'sociological tendency' with the essay form. According to Coutinho , the essence of the essay lies less in attempting something and more in the notion of study, where writers are primarily engaged in exploring the factual aspects rather than indulging in fictional realms. In his words, "[…] they are not truly essayists, but rather philosophers, historians, sociologists, political thinkers" . Another issue is that the argumentation should address the intricacies that this literary support would encompass in condensing a tradition that has been reinvented over the course of two centuries. While in the formation of the state, the essay encompassed elements of political philosophy that encompassed sociology, towards the end of the 19 th century, as Candido argues, the sociological tendency became more implicit. Taking these considerations into account, it is necessary to assess the notions of space and time in the essayistic interpretation of Brazil, with the goal of framing the imaginative cartography and the figuration of the modern chronotope through social and sociological theory. Regarding the topic of space and its role in shaping his interpretation of Brazil, Duarte stated: In this analysis, let us emphasize from the outset that one of the most determining physical factors in shaping the form, style, and orientation of Brazilian social organization is not solely the climate, its biochemistry, flora, or fauna. It is, in fact, the territorial expanse available to and required by the people to meet economic needs and pursue the aims driven by economic instincts or ought to be driven. Every form of production in Brazil has had and continues to have a large-scale approach. Above all, it is a production of space . In fact, authors such as Oliveira Vianna , Paulo Prado , Gilberto Freyre , Caio Prado Junior , Sérgio Buarque de Holanda , Nestor Duarte , and Afonso Arinos de Melo Franco highlight the elements of rural life in Brazil, characterized by its unique features: their isolation, the absence of an internal market between different segments, the centrifugal force of an agro-exporting economy, the relatively weak urban centers and their players, the challenges of colonization and land occupation, the lack of roads and communication infrastructure, and the limited presence of the state in establishing internal public regulations. Each rural nucleus, or each complex between the 'Casa grande' and the 'Senzala' , would be a social microcosm, a small collective organism, with full capabilities for isolated and autonomous living. These phenomena, with their cultural and sociodemographic roots, would allow essayism, through its conceptual tools, to interpret the modus operandi of certain oligarchic structures of domination that are incompatible with the establishment of a liberal democracy, yet highly effective in acquiring, organizing, and exercising power in a hierarchical manner. The prominence of certain individuals and their figuration-social action within a network of interdependence-would form the basis of the interplay between politics and society. This type of clan-based solidarity, linked to historical heritage, did not seem destined to disappear as a mere consequence of development or modernization in the political sphere. It would be like a cultural constant, a kind of amalgamation of the national collective psychology. The existence of this pattern of domination is intertwined with the absence of a spontaneous articulation of interests between social groups and the apparatus of the state, which, in turn, would be obliged to interact with these social groups through vertical structures of power, with the rural clan chief, landowner, landlord, or patriarch at the top, depending on the designation given to this character in each work, marking this civilizing process ). It would become evident for sociological essayism of the 1920 and 1930s that political power and social power would organize themselves pyramidally, in such a way that each rural chief would connect to another to form a structure of domination articulated through reciprocal exchanges, as seen in analyses of issues such as political patronage based on gratitude and/or friendship, matters related to an ethic of cordiality, and the specification of pivotal points of patriarchy as foundations for the failure of liberal ideals and institutions. One conclusion would be that, in this type of sociopolitical construction, there would not have developed a national or public interest transcending immediate and particular interests. In this political activity, instead, there would be a purely partisan and exclusive conception, exercised and consumed strictly within the small circle of the group, the clan, the faction, the local directory, the family. In summary, based on the latifundium and rural life, the type of solidarity that formed and the stability that revolved around family groups, which allowed for the formation of a web of stable, permanent, and traditional social relations, with the patriarchal figure of the pater familias as the source of authority, led to Acta Scientiarum. Human and Social Sciences, v. 45, e68368, 2023 patrimonialism in the handling of the public sphere, the subjugation of private interests over the public interest, and the establishment of a social ethic based on sentiment. The large rural property and, consequently, the notion of agrarian exclusivity and the simplifying function of latifundia became crucial in this explanatory model of the conditions in which solidarity and interests were formed in the peculiar Brazilian case. With the differences acknowledged, these interpreters of Brazil realized that this simplifying function would hinder trade and the emergence of a commercial bourgeoisie or an industrial class, which would be concentrated on the coast or in small towns inland, but without any political power. Thus, between the class of free workers and the landowning aristocracy, solid bonds would not be formed, accentuated by the absence of a middle class of the European type. It is during the 1920 and 1930s that the Brazilian essayism experienced a significant increase in the proliferation of its arguments, particularly in relation to its connections with modernism and the political sphere. These essays of general interpretation are closely tied to the emergence of Brazilian sociology and have since become classics in the field of interpreting Brazil. Due to their genre, the essay, they have become an integral part of the tradition of sociological discourse known as essayism. Critiques and analyses of Brazilian essayism as a whole offer us valuable insights into how this form of writing was conceived and examined within the Brazilian context ). Thus, we undertake a three-fold exploration with the aim of constructing an interpretation of Brazilian essayism. Firstly, we delve into interpretations of Brazilian social thought through the lens of space, connecting it to the quest for defining the significance of the imaginative cartography crafted through the fusion of social theory and Brazilian social thought itself. Secondly, we examine the social theory of meanings and the potential of figuration as an interpretive framework for Brazilian social thought. Lastly, we investigate the convergence of imaginative cartography and figuration in shaping the modern chronotope and its relevance to interpreting Brazilian social thought, with a specific focus on the essayism of the 1920 and 1930s. By reexamining some of the most prestigious essays originally published between the early 1930s and the mid-1940s, we probe into their interpretative affinities around two correlated questions: on the one hand, the conceptions of time that implicitly or explicitly underlie their views on the intricacies of Brazilian social life and, on the other hand, how such notions predetermine their ideas about the asymmetric place and the particular condition of this society in the modern world. We conclude by examining the correspondences and symmetries between these authors representations of Brazil, showing that they tend to allude to a temporality that is only partially in synchrony with social and political visions of modernity ). While revisiting some of the most acclaimed oeuvres of the so-called Brazilian social thought, we examine the feeling of temporal mismatch that underlies a wide variety of portraits of social life in Brazil. We contend that notwithstanding the variegated analytical perspectives inherent to this intellectual constellation, most of these oeuvres are inclined to ascribe to Brazil a peculiar temporal configuration, only partially synchronized with the homogeneous and linear-progressive time envisaged in modernity. That said, we also interested in investigating a set of critical propositions to the sociological imagination in order to assess an additional hypothesis, namely: these very same visions of Brazilian society seem to insinuate an alternative theoretical frame of reference, sensitive to the unbalances, asymmetries and contradictions that crisscross modernity's temporality. The hypothesis of Brazilian singularity is the single most powerful idea in Brazilian social thought. As no other, it has succeeded in circumscribing and shaping the agenda of research and reflection concerning the country's social experience. Conjured up a entirely unique compared to others, Brazilian society is elevated to an analytical category and, in the same measure, a privileged object of investigation, worthy of specific explanatory and interpretive efforts ). --- Excesses and absences: the brazilian modernity diagnosis Together, but not as a unified whole , and beyond the intellectual context from which these diagnoses emerged, the distinctive feature of Brazilian essayism, in operationalizing concepts such as patriarchy, familism, patrimonialism, personalism, agnatism, clientelism, and the myriad of privatist obstacles enshrined in its ideals, is the decisive role in the constitution of public life. In the tradition of Brazilian political and social thought, the emergence of this theme is recurrent. There are positions that glimpsed this interpretive path in the 19 th century, but essayism provides it with new concepts and assertions. In these terms, the recurrent appearance of such a conceived public life can be understood either as manifestations of outdated and definitively surpassed readings of reality or as a legacy of interpretations with varying degrees of plausibility . Instead of assuming a characterization of public life as settled or surpassed in historical or analytical terms, it seems more productive to problematize its role as an explanatory device for the ambiguous configuration of the Brazilian public sphere. The recurrence of this theme appears through the literature and the object of study in a dual aspect. On one hand, in the realm of ideas, it entailed a nuanced examination to reconstruct the specificity of the approach and understanding of the public sphere by the essayism of the 1920s and 1930s, namely its emergence, crystallization, reproduction, and analytical method . On the other hand, the centrality of this theme can be explored as a phenomenon in which fundamental dilemmas of the configuration of the Brazilian public sphere and its private counterpart become apparent, highlighting historical difficulties brought about by the emergence of the modern State in peripheral environments . Analysts of hegemonic modernity may not have realized that the process of modernization leading to Modernity could not assume a Westernization of modernism that starts from the center and extends to the periphery . European modernity was unable to uniformly transcend its values and aesthetic standards to the rest of the world without upheavals, as the process of modernization differed across various areas of the world. For Eurocentric social/sociological theory, what characterizes modernity is the partitioning of reason, that is, its differentiation into institutionally autonomous spheres. Historically, the differentiation of the political system occurred when political authority crystallized around legal positions that control the means of force. Within the framework of societies organized around the state, markets emerged and acquired their own logic. These systems are formally organized domains of modern social action, with their historical beginnings in the political revolutions of the 18 th century and their subsequent cultural and philosophical manifestations . Thus, Modernity emerged as a project on European soil, with the establishment of the organizing principle of modern subjectivity and the separation of spheres of value. Self-referential in its historical consciousness, it had to derive its own normativity from within itself. In the case of Brazilian essayism, more or less explicitly present in the interpretations proposed by the authors above mentioned, we find the idea that, in their contemporary Brazil, the State, economy, and civil society were never fully able to differentiate themselves and become dynamic based on their own logics and codes. The public domain would be abducted and subjugated to the logic and purposes of family realms, personal and private codes, with restrictive sociability. That is why impersonal and rationalized rules were often relegated to a secondary position. In this society, the degree and extent of social differentiation, secularization, and the separation between the public and the private observed in central modern societies were never achieved. 3This matrix of Brazilian social and political thought expresses an alternative path to modern development through its dichotomies, both in the composition of an imaginative cartography and in the figurations of social action . Such peripheral intellectual experience would carry a contradiction as the foundation of its modernity, particularly in how it approached space and its characters within the modern chronotope. In other words, while seeking to explain this difficult synthesis, the authors would understand Brazilian modernity in terms of contemporaneity and historicity, and from the perspective of a kind of alternative modernity or as a non-model path of Modernity . The countryside would have its own sociology, its main characters with their subjectivity and agency in the world. The latifundium would serve as a backdrop for the realization of interests and virtues for the landowner; the slave, the henchman, the common free man, and the slow passage of time would shape social life and establish certain types of solidarity and interests. The city would be the site of social interrelations and the locus of fast-paced time, initiative, the lust for modern living, with its liberal characters and sociability often subsumed under the rural world and unable to find fertile ground for its advancement. Acta Scientiarum. Human and Social Sciences, v. 45, e68368, 2023 The understanding of the city and the rural world would involve analyzing all the elements that compose their framework: land, water, climate, people, civilization, culture, architecture, labor, ideas, symbols. The countryside and the city would not only be materiality; they would possess a symbolic and subjective dimension that would also shape their spatial forms. The significance of space, whether urban or rural, would give individuals and communities unity and identity with their surroundings, in a sort of signifying structuring of space. Each place would shape an imaginative cartography that attributes certain ways of living, thinking, and experiencing the world to a specific time-space, certain social types, a particular solidarity, and a certain constitution of interests and virtues in its sociability, all aimed at revealing an alternative to hegemonic modernity with its excesses and absences in a dialogic manner. --- Conclusion In this article, we examine Brazilian essayism from the 1920 and 1930s as an interpretation of Brazil that considers the meanings of Brazilian collective action and the resulting political culture in the formation of its nation-state. The explanatory role of this strand of Brazilian social thought reflects the possibilities and constraints that arise outside the traditional and modular explanations of hegemonic sociology. With these characteristics, the characters in historiography gain intelligibility and plausibility within the framework of social theory that guides these interpretations that seek to employ history as an analytical method for understanding society and the state. This approach postulates that the foundations and concepts of sociology are best suited to uncover the origins and uniqueness of the country and its history, thus establishing a strategy that constitutes a theory of interpretation. Undoubtedly, the leadership arising from rurality and its manifestation in solidarity, authority, and the composition of interests would constitute specific social types. Most importantly, it is the actions of these characters, these social types, within Brazilian history, in their public realm, and in the formation of the state that matter. When isolated from this broader analysis of their social and political agency and constitution, the different characters lose their depth. Around the imaginative cartography, encompassing the countryside and the city, the coastline and the hinterland, the center and the periphery, their interweaving of themes such as solidarity, authority, freedom, and equality, their figuration through composite characters driven by specific interests and virtues, demonstrate that the overall concern of essayism surpassed the criteria of a strictly culturalist interpretation of the country. The central and mobilizing concepts, such as patriarchy, patrimonialism, familism, among others, served to elucidate the configurations of the relationships between the state and society. These were relationships that could be intertwined in the process of forming the political community, in the bureaucratization of public power, in the formation of social solidarities connected to such types of authority in the constitution of subjectivities. Lastly, it is important to point out that the development of distinct national or regional sociologies, especially in peripheral contexts, has emphasized the differences in historical trajectories as a singularity of peripheral modern experimentation , anchored in the delay or inadequacy between theorization developed in hegemonic contexts and its production, circulation, and acclimatization in peripheral contexts. This perspective can be understood from the center-periphery framework of the worldsystem , multiple modernities , or global modernity . Simultaneously, it becomes essential to investigate the relationships between social/sociological theory and Brazilian social thought, which gives rise to the demand for sociological theorization from the margins to provide alternative explanations on global topics such as modernism, modernization, and different configurations of modernity . This approach allows for the reformulation of sociological theory and the realignment of the meanings and significance attributed to social actors throughout the historical development of these areas.

The paper aims to analyze the Brazilian essayism through the category of modern chronotope and reflect upon the theoretical junction between imaginative cartography and figuration as interpretative axes of essayism and Brazilian social thought as an example of peripheral intellectual experience, highlighting the multiple paths and interpretations of Modernity.

Introduction Over the past 30 years, a consensus has emerged about the need to protect what is left of the planet's biodiversity. This globally shared social acceptance opens a multifaceted debate on the best ways to achieve this goal. Taking a Foucauldian perspective, we understand the emergence of 'biodiversity conservation' as the social construction of an object of knowledge and, therefore, a space of power relations . Throughout this historical process, different models of practices and discourses have become preponderant. The first global model for conservation, based on the implementation of restrictive and large Protected Areas, came to be known as 'fortress-conservation' . This model was severely criticized due to the --- Research Communications --- Special Issue on Diverse Conservations In our perspective, this polarization does not account for the complexity of conservation disputes, in a context where social inclusion is becoming increasingly mainstream. We argue that the construction of viable solutions for conservation could benefit from material attempts at dialogue among diverse groups of people working towards a more sustainable future. Nonetheless, many conservation policies continue to generate situations experienced by local populations as injustices. We understand environmental justice as key for the longterm involvement of those who have been sharing those environments for centuries. Thus, we seek to contribute to a convivial approach to biodiversity conservation , that sees the dialogue among different perspectives and radical equity as fundamental tenets for discourse and action to protect ecosystems. In this paper, we focus on the discursive disputes around biodiversity conservation in a specific territory, relating directly to environmental narratives of those who live in and seek to protect the Brazilian Atlantic Rainforest. We apply a qualitative analysis to compare solutions to the shared problem of biodiversity degradation of the Atlantic Forest proposed by two different groups of people: the solutions developed by Tupinambá Indigenous people and the institutionalized western science-based environmentalism developed by state agencies and non-governmental organizations who work with conservation projects in southern Bahia. We avoid universalizing solutions, trying instead to compare the concrete solutions presented by each narrative. We understand that although indigenous-and other traditional-knowledges have their construction grounded in concrete life experience and not in generalization, they should not be seen as less valid than science-based perspectives . Nonetheless, in conservation planning and implementation so called 'evidence-based' perspectives tend to have more legitimacy, despite the continued efforts toward showing the social and cultural injustices it produces. The solutions provided by more powerful actors in conservation, namely conservation biologists and ecologists that act in academia, NGOs, and state agencies, fail to account for the overlying power relations and causes of conflicts around conservation, including the detachment to local perspectives and excessive bureaucratization . With our case study, we wish to contribute to the ongoing advocacy for more effective pluralism in conservation . The methodology based on the analysis of environmental narratives makes it possible to compare and equalize the solutions proposed by representatives of commonly empowered decision-makers in environmental issues and representatives of commonly marginalized discourses. Through the equal juxtaposition of narratives that usually are perceived in a strict hierarchy, we wish to shed light on concrete challenges for mitigating the recurrent conflicts around conservation planning and implementation. We also illuminate the actual possibilities of building alliances between different perspectives. We conclude by advocating for pluralism in conservation, through direct engagement with the proposed solutions offered by on-the-ground agents of Indigenous life and struggle. --- The Territorial Contours The geographic scope of this research is composed by the Tupinambá de Olivença Indigenous Land, Una Biological Reserve and Una Wildlife Refuge , located in Southern Bahia, in northeastern Brazil, an area once completely covered by the Atlantic Forest biome . The Brazilian Atlantic Forest hosts one of the world's most diverse and threatened tropical forest biota of the world . Only around 26% of its original cover remains , with severe defaunation . The South of Bahia is the second largest remaining fragment of the biome in Northeastern Brazil, though it is threatened by intense processes of deforestation related to plantations, mining, and tourism enterprises . Before colonization the lowlands of the Atlantic Coast were occupied by Indigenous Peoples, mainly from the Tupi linguistic community. Through the colonial period, the lands that today form the Tupinambá de Olivença Indigenous Land were occupied by a Jesuit-controlled Indigenous village. During the nineteenth century, cocoa gradually became the main monoculture for export in the region and the Brazilian state officially declared the 'extinction' of the Indigenous populations, authorizing the alienation of their lands . Around the 1980s, cocoa production was deeply impacted both by the spread of pests and overseas competition. The crisis in cocoa intensified --- Research Communications Special Issue on Diverse Conservations deforestation and impoverishment. Most of the cocoa in the region was planted in a system called 'cabruca', which consists of a plantation that maintains part of the original Atlantic Forest, to take advantage of shade. Given the low profitability, several landowners, predominantly from white and settler communities, resorted to timber to pay off debts. At this moment, a conservationist movement emerged in the 'Cocoa Cost', aiming to contain the accelerated process of deforestation. In 1994, the Institute for Socio-Environmental Studies of the South of Bahia was created and quickly became the largest NGO with an emphasis on biodiversity at a local scale. This NGO was a main actor in a process of enlargement of the local protected areas network during the 2000s. The Biological Reserve that had been implemented in the early 1980s was enlarged in 2007, giving it 18,715.06 hectares. This process was accompanied by the creation of a new PA, the Wildlife Refuge, with 23,262.09 hectares, functioning as a buffer zone for the Biological Reserve and overlapping with some portions of the Indigenous Land. Concurrently in the late 90s and early 2000s, a renewed Tupinambá Indigenous movement rose. Reframing their cultural past and present , the Tupinambá enacted certain political strategies, among them, the 'retomadas' : the reappropriation of something that was usurped from the Indigenous peoples in the past. The 'retomadas' are mainly expressed in the effective occupation of lands and are used as a way to pressure the Brazilian state to ratify Indigenous titles to Indigenous Lands. However, this political-cultural strategy goes beyond the sphere of negotiating rights, constituting a dimension of autonomy for Indigenous movements and the construction of new landscapes. In this sense, they have an ontological dimension since they provoke reorganizations of material and immaterial territories . The Indigenous Land is, therefore, the result of an intense politicalcultural process performed by the Tupinambá through which they actively take back their land and history . In 2009, the first official map was published by the Brazilian state in which the Indigenous Land consisted of 47,376 hectares . This demarcation, however, has never been ratified by the Ministry of Justice, and thus remains more legally vulnerable than the Protected Areas. Since those processes occurred concomitantly, efforts were made to assure the smallest overlap possible according to diverse expectations . Nonetheless, as we shall demonstrate, the implementation of the Protected Area led to conflicts due to reinforced environmental monitoring experienced as injustices by Indigenous peoples. Therefore, despite the attempt at finding middle ground, the paths for conservation remained disputed and uncertain, since legitimacy for choosing the best paths for biodiversity conservation remained unequal. This makes it important to look at the different proposed solutions for biodiversity conservation and recognize to what extent they have the power to --- Research Communications Special Issue on Diverse Conservations effectively become a central guidance for conservation. --- Methods Our analysis is based on the comparison of the environmental narratives of two groups: 'Indigenous' and 'institutionalized scientific environmentalism.' Different actors have different access to the discursive power to define what should be understood as environmental degradation, as well as its causes and solutions. In order to approach these power relations, we analyze 'environmental narratives' , understood here as stories bounded by the narrators' particular experiences, observations and attachments to place . The narrative concept was used as a tool to compare competing knowledge systems bounded to place, including those based in western cosmologies . The selection of materials that could compose such narratives was guided by the aim to access views over an urgent problem shared by both perspectives, namely, "the need to protect what is left of the Atlantic Forest". The main sources of access to the Tupinambá narrative were 20 interviews conducted with Tupinambá people in 7 villages inside Indigenous territory, and participant observation during fieldwork conducted in 2016-2017, when conflicts between the Indigenous population and local state agencies were unfolding due to environmental fines received by the Tupinambá. The Tupinambá interviewed by the researcher were defined by the coproduction relation between the researcher and two Indigenous leaders. This choice took into consideration gender, age, and territory range, but had the Indigenous people and leaders of communities that were in direct involvement with the disputes around conservation issues as its main criteria. On the other hand, the set of discursive materials that comprise the institutionalized western sciencebased environmentalism narrative is linked to the performance of IESB and its partner institutions, due to its prominent role in Southern Bahia and influence in decision-making. In this case, we drew upon 8 scientific papers, 15 project reports, and 10 interviews with members of IESB and the local agents of the national Brazilian agency for biodiversity conservation. Therefore, the second narrative is composed from people's personal experiences and perceptions, as well as the available documents and projects developed by governmental and non-governmental established institutions that work directly with conservation implementation in the region. Analysis of the data was conducted through the identification of repeating categories on the materials that composed each narrative related to the causes and solutions for biodiversity degradation. The most recurrent topics became unifying themes that composed each narrative . Each of these unifying themes was systematized in a table per document/interview per narrative and all data was then condensed to the three causes and solutions most present in each narrative. Therefore, drawing from the field work and collected materials, we have identified the general contours of two different perspectives on the same issue, making it possible to compare contrasting perspectives on biodiversity conservation. In the results section, we point out three main causes for the shared problem and its related solutions according to each narrative. Our main objective is to bring into dialogue points of view about the best paths for forest management that have considerable differences in terms of language and social legitimacy, to move closer to plurality in conservation. --- Results --- Institutionalized Environmentalism Narrative Traditional strategies for biodiversity conservation have emphasized the creation of intact protected areas, free from human presence. While these areas have enormous potential for conservation, long-term conservation of biodiversity requires the development of an approach that includes the management of buffer zones and biological corridors. The main argument that stands out in the institutionalized environmentalism narrative is the defense of the 'bioregional paradigm' for biodiversity conservation. The restriction of conservation planning to Protected Areas is considered one of the main causes of the degradation, and the solution would thus be planning on a wider landscape scale . Categories such as 'corridor' and 'network of protected areas', are recognized as the basis for biodiversity conservationespecially in the context of the Atlantic Forest. Conservation efforts should be geared towards maximizing habitat connectivity, ecosystems, and ecological processes, facilitating genetic flow, and increasing the chances of species survival. For these --- Research Communications Special Issue on Diverse Conservations precepts to be followed, scientifically grounded planning is crucial. Geographical Information Systems are recognized as a good basis for decisionmaking because of their ability to provide rapid information on landscape dynamics . By identifying priority areas, the environmentalist narrative proposes a series of solutions that are intrinsically related to each other as part of a coherent discourse. --- Solution #1: Actions in Human Occupied Areas and Social Participation The adoption of a more comprehensive scale for biodiversity requires activities for conservation outside Protected Areas, necessarily including human populations in the equation. The solution proposed seeks to keep the Protected Areas as intact as possible and, at the same time, to work with local communities that inhabit their surroundings. Thus, the inclusion of so called 'social dimensions' is a founding element of the narrative, but this inclusion appears in specific terms. The most relevant publication on the theme produced by IESB aims at "analyzing the opportunities to reconcile economic and conservation use of areas" . The proposition is to generate mechanisms to compensate landowners for environmental services provided, stating that areas with less potential of profitability and greater potential of environmental services should be privileged . Another form of argument is the need to create participatory spheres for the implementation of biodiversity projects, such as decision committees and advisory councils. In several of the activities carried out by IESB and partners in the region, participatory workshops were implemented, although the profile of the members of these participatory meetings is quite specific: State agents, NGOs, and researchers. Environmental education is another cited path to solve biodiversity degradation, which is presented as complementary to participatory processes. This instrument is seen as a way to change people's behavior by bringing them environmental awareness about the value of inhabiting the surroundings of a biological reserve . --- Solution #2: The 'Cabruca' Identity In Southern Bahia, the proposal to carry out biodiversity conservation management on a broader scale is linked to the need to confront the cocoa crisis through a new development model . This narrative argues that, in the face of the lack of financial return of the cacao plantations, the pressure on timber resources increases, mainly in the areas of 'cabruca' agriculture . Landowners, as a form of economic complementation, may prefer to create pastures in areas once covered by forest or 'cabruca'. The expansion of pastures is seen by environmentalists as the central cause of degradation. To the institutionalized environmentalism narrative, the solution is to encourage organic cocoa plantation, to promote the maintenance of 'cabruca' areas and to stimulate alternative productive activities for local agriculture. In order to justify this point of view, research projects were carried out to demonstrate the occurrence of several species of plants and animals in 'cabruca' areas and its connective capacity between forest fragments . It is also worth mentioning that the valorization of 'cabruca' is linked to ideas of a regional identity: the environmentalist narrative points to the social and historical value of cocoa culture, affirming the importance of the 'personality' of the region as a path to an integrated sustainable socio-economic development . --- Solution #3: Expansion of the Network of Protected Areas According to this narrative biodiversity conservation, especially in the Atlantic Forest, necessarily depends on the expansion of the Protected Areas network . Advocacy for strengthening monitoring of existing Conservation Units and creating new ones is recurrent. The creation of Private Reserves is also encouraged, although it is seen only as a complementary solution . In fact, all solutions are only seen as effective if they are combined with large restrictive Protected Areas, thus forming the basis of the conservation landscape system. Land regularization through compensation payments and the relocation of human inhabitants within Parks and alike is prioritized here . On the other hand, these areas are intensely populated by a myriad of non-human living beings. The choice of priority areas for biodiversity conservation is largely anchored in the behavioral patterns of animal species. In all institutional documents, endemism and the risk of extinction of certain species are recognized. The framing of the problem in the institutionalized environmentalism narrative is strongly influenced by threats to certain species, which are often defined --- Research Communications Special Issue on Diverse Conservations through global indicators such as Important Birdlife Areas and Key Biodiversity Areas . Lack of knowledge about the different species is widely seen as a cause for the problem: according to the analyzed documents, the lack of data on the occurrence of threatened species makes it harder to push for more restrictive environmental protection policies. --- Indigenous Narrative Conservation Tupinambá Leader in Interview 2017 When field research was conducted, the Indigenous narrative was marked by feelings of injustice in relation to fines for environmental crimes. In the areas of overlap and buffer zones of the protected areas, environmental monitoring is intense, and, in recent years, several Indigenous people have been accused of suppressing vegetation in areas considered 'regenerating forest' in accordance with the Atlantic Forest Law . Unsurprisingly, the Indigenous narrative evidences indignation in relation to punishment for an act that they do not consider to be in any way criminal. The practice of crop rotation is common among the Tupinambá de Olivença and has been used historically . In the view of the Tupinambá, agriculture for family sustenance should never be considered deforestation. The Tupinambá understand deforestation as the withdrawal of what they call 'thick wood' or 'hardwood' from areas of 'dense forest' or 'native forest'. On the other hand, what is perceived by the environmental agency as 'regenerating forest' falls within Indigenous categories such as 'arrancador' and 'capoeira'. 'Arrancador' is recent vegetation that grows in lands with little rest time and is generally described 'growing up to three feet from the ground'. 'Capoeira' is vegetation somewhat higher than the 'arrancador', endowed with 'fine woods' or 'white woods', which can be felled 'with machete and ax'. The common point of view of all Tupinambá is that other types of land use should be forbidden in areas described as 'dense forest', since this would mean 'deforestation'. Therefore, most Indigenous formulations on the best ways to conserve nature are connected to land use according to certain restrictions autonomously decided by them. In the Tupinambá view, there is a clear distinction between a use that would cause 'environmental destruction' and one that would take into account the 'times of nature', taking less than the land can produce again over time. --- Solution #1: Recognition of Indigenous Land Claims In the Indigenous narrative, the main vectors of 'environmental degradation' are large enterprises with high impact capacity. If their land claims could be fulfilled, they believe they would have the power to halt those activities in their territory and therefore become contribute to growing examples of effective conservation on Indigenous Lands in Brazil . The subject of such activities are variously named by the Tupinambá: the 'outsiders', the 'miners', the 'powerful', the 'non-Indians', or the 'fazendeiros' . The impunity of these other groups in relation to activities of high social and environmental impact within the Indigenous Land aggravates Indigenous feelings of injustice about the fines. The 'care for nature', an Indigenous concept that relates to their ability to take care of the 'times of nature' constitutes for the Tupinambá an element of alterity in relation to the non-Indigenous people living in their territory, especially in relation to the 'fazendeiros'. In the Indigenous narrative, the 'fazendeiros' have no relation to the land, because they do not depend on the water that flows through it and on the quality of the environment when raising their children and grandchildren. Therefore, they devastate with impunity. Among the highly impactful activities, the most frequently mentioned by the Tupinambá is sand mining. The sandbanks are seen as disastrous and were named as a main cause to biodiversity degradation by all Tupinambá interviewees. Sand extraction for the construction industry generates enormous craters that, in addition to the deforestation, cause springs to dry up. This directly affects Indigenous families, and often involves the removal of natural fields containing the 'piaçava' tree , a source of income and an important element of Tupinambá cultural life. Another high-impact activity is the large-scale monocultural planting of coconuts and palm hearts. The Tupinambá de Olivença also vehemently condemned timber logging and the active presence of agents of real estate speculation. In the Indigenous narrative, the ideal environmental solution that would ameliorate all the --- Research Communications Special Issue on Diverse Conservations framed causes would be confirmation of Indigenous Land titles, which would allow Indigenous peoples to deepen their ties to their territory, encouraging preservation for their descendants. --- Solution #2: 'Retomadas' The Tupinambá develop, within the areas that come to their management through the practice of 'retomadas', transformations in the landscape to protect nature. The diversity of actions that are carried out in the 'retomadas' by the Tupinambá to 'preserve', include: efforts to maintain the 'forest in the spring area'; restoration in pasture degraded areas; closure of charcoal stores; production of several crops in the same space, so that the different species help each other; extraction of raw materials such as 'piaçava straw', 'imbira shells' and 'aroeira seeds' used for crafts and/or sale respecting their times of regeneration; among others. The 'retomadas' are seen by the Tupinambá, especially their leaders, as 'seed-boxes' for actions that point in the direction of preservation. The Tupinambá widely recognize the possibility opened by the 'retomadas' for more autonomous management of their collective labor and also control over their territory. This ability to organize the work is aligned with the possibility of collectively deciding on the management of the territory, making choices in terms of the varied uses of the different areas based on their own criteria. --- Solution #3: Income Alternatives and Educational Seminars The Tupinambá accept, to some extent, monitoring activities as a solution for environmental degradation, as long as they penalize practices that they consider to be causes of deforestation. Indigenous peoples also point out that the prohibitions, if indeed necessary, could be enforced by them. One of the main concrete proposals in terms of conservation-related public policies, reiterated by a significant number of Indigenous leaders, is the hiring of Indigenous brigade fighters to contain fires and Indigenous rangers to curb deforestation. The monitoring would, however, be carried out in accordance with Indigenous criteria. In addition, the possibility of conducting 'educational seminars' is present in the Indigenous formulation of solutions to the biodiversity degradation problem. The main objective of such seminars would be to open a space for dialogue, where joint alternative land management strategies could be developed, in accordance with collectively established environmental limits. Hunting is a good example of how the limits are established: for instance, crabs must be larger than a fist to be collected and pregnant females of all mammals cannot be disturbed. It is important to emphasize that, in the view of the Tupinambá, monitoring would only have some effect if accompanied by alternatives to generate sustenance for Indigenous families. In a context of limited financial resources, and in some cases extreme poverty, authoritarian bans do not reach their conservation objectives. --- Discussion When we analyze the solutions proposed by each narrative, we can see resonances and divergences. First, both narratives present themselves as 'counterdiscourses', since they challenge dominant perspectives by advocating for the conservation of forest areas: the mainstream perspective on the development of the region advocates for the implementation of plantations, large tourism enterprises, and resource extraction . Both stress the importance of engagement, participation, and environmental education. In addition, both narratives consider the economic aspect and the need to generate income alternatives that are sustainable, albeit in different forms. Those similarities can open paths for joint efforts and could be used as middle ground to develop alliances, for instance, by including the indigenous populations as main beneficiaries of sustainable alternatives. However, the narratives diverge in relation to the degree of use and integral protection in different areas. The Indigenous statements present some criteria to choose areas for use that would not necessarily be recognized as 'sustainable' by the institutionalized environmentalism. As stated previously, for the Tupinambá, hunting may or may not be a cause of degradation, depending on who does it and how it is done: they recognize a difference between 'Indigenous hunting', that respects limits regarding the time and species that can or cannot be a target, and 'predatory hunting', the irresponsible attack of any of the wild animals by 'outsiders'. In the institutionalized environmentalism narrative, hunting is necessarily a cause of biodiversity degradation in all forms, and it is as a threat perpetrated by the populations surrounding the Protected Areas, since the 'human actions' are recognized in a generic way, without a specification of the groups responsible for degradation. The Tupinambá, on the other hand, recognize that the 'big and powerful', not themselves, --- Research Communications Special Issue on Diverse Conservations are responsible for the activities that 'really destroy the environment' and, therefore, should be contained by law and enforcement. A dichotomous view of the disputes over biodiversity conservation does not account for the complexity of relations in this case and other territories where conservation is at stake. On the one hand, the a priori perception that environmentalist and Indigenous narratives would be mutually exclusive, since the former would tend to overlook environmental justice, can become an obstacle for alliances between environmental actions and Indigenous perceptions on forest management. On the other hand, a vision that sought to recognize an automatic alliance between the Indigenous movement and a 'socio-environmental' movement would be equally difficult. Unlike the institutionalized environmentalist narrative, the Indigenous narrative illuminates how processes occur and how they could be better but does not articulate a fixed set of principles about how things should be done. Any coalitions among these perspectives need to take into account this epistemological difference. Several factors give the different groups a greater or lesser capacity to publicly legitimize their perceived solutions for the problem. In the case in question, through political organization, the Tupinambá reach greater capacity to convince other actors and to manage their territories. However, their access to resources for biodiversity conservation is low when compared to institutionalized environmentalism, since most decisions of high impact related to biodiversity conservation in the region were taken in arenas from which they were excluded. The Tupinambá are not an isolated case: conservation policies, even when they seek to address the ethical issue of marginalizing local populations, often reinforce exclusion dues to the ontological dimensions that define the different interventions . In this scenario, injustice is aggravated by the power differentials relating to juridical and political authority between the protected areas and the Indigenous land. The Brazilian bureaucracy created a complex, expensive, and hard demarcation process for Indigenous lands, which creates a sort of 'obstacle race' permeated by several politicization processes . The Protected Areas implementation on the other hand, although complex, is rather faster, making it easier for environmental institutions to make their solutions prevail. --- Conclusion The need to address social justice and participation is becoming mainstream, and yet, the overlying power relations still play a role in the actual legitimacy of diverse proposed solutions for concrete environmental problems. The upfront identification of the solutions for the Atlantic Forest proposed by both sides shows that they are equally coherent, and that there is room for bridges between the perspectives. The above-mentioned differences in social legitimacy and territorial effectiveness, however, show the stronger weight of the institutionalized environmentalism in actual decision-making. This case illustrates the importance of recognizing non-dominant imaginaries for the future . We hope that this can inform contestation of knowledge production and decision making . Current times of accelerated deforestation urge for the formation of all possible alliances and an in depth understanding of knowledge-power relations in each context is crucial to make a fertile ground for that. We argue that our method of making the divergent perspectives as equal as possible can contribute to tackling those power relations. This is a key step to move beyond the perceptions of inconsistency typically recognized by institutionalized environmentalisms on Indigenous and other traditional ecological knowledges . Pluralism is needed to contemplate not just the different proposed actions impacting the prosperity of all living beings, but also to recognize the diverse values that guide relations to nature and their implications on the recognition of the main causes behind biodiversity degradation in the first place . Just conservation is more effective in long term but can only be pursued through historical reparations that should encompass both dynamics of land dispossession and colonial knowledge structures . --- Acknowledgments Thank you to all people involved in this research, especially the communities of the Mamão, Serra do Padeiro, Itapuã, Tupã and Tucum of the Tupinambá Indigenous Land for their trust . Thank you also to all members of Instituto de Estudos Socioambientais do Sul da Bahia and the Instituto Chico Mendes para Conservação da Biodiversidade for the support, time and access to documents and reports. This work was fully funded by the National Council for Scientific and Technological Development , and the article --- Research Communications Special Issue on Diverse Conservations

injustices its implementation created (Adams and Hutton 2007). Restrictive PAs often do not encompass social and cultural heterogeneities, creating negative impacts on otherwise sustainable livelihoods. The consolidation of this critique led to the mainstreaming of more inclusive models of conservation, such as participatory conservation and community-based conservation, that became the global paradigm in the late 1990's. Thereafter, the debate on biodiversity conservation took a polarized form, stressing the role of local populations in conservation: one 'side' advocates for the restriction of access and circulation, and the other recommends community involvement as a solution to conflict (Holmes 2009).

Introduction The letters and reports sent to the Neo-Assyrian kings Esarhaddon and Ashurbanipal by practitioners of the scribal arts of celestial divination, exorcism , pharmacology , extispicy and lamentation represent our earliest evidence of the application of divination as well as our only AVAR as the Middle Assyrian period, and scholarly texts copied from Babylon and Nippur are widely attested in temple archives and private collections from Aššur and Kalhu for centuries before Sargon's conquest of Babylonia from 710-707 BCE. 9 Others have suggested that political instability led to an increased demand for supernatural protection on the part of Assyrian kings during the seventh century BCE. 10 Recently, Eleanor Robson has linked official support for scholars to official veneration of the scribal god Nabû, which received extensive state support from the reign of Sargon II onwards. Robson argues that Ashurbanipal was the last Assyrian king to maintain an extensive scholarly retinue, and that state support for scholars declined steadily as a result of a general economic decline in the aftermath of the war between Ashurbanipal and Šamaš-šumu-ukin from 652-646. 11 Entangled with this question is the extent to which Assyrian kings followed the recommendations of their scholars when making practical decisions about how to run the empire. It is difficult for modern minds to imagine that Neo-Assyrian rulers maintained a functional empire for the better part of three centuries while regularly making important political decisions on the alignment of planets or protrusions from the liver of a sacrificial sheep, and many scholars have argued that scholars served a propagandistic purpose by reassuring the populace that the king enjoyed the favor of the gods. 12 Similarly, Eckart Frahm has argued that by presenting the king with many possible interpretations, scholars ensured that whatever decision he made was arguably 'correct' according to the omens. 13 Others have suggested that scholars under Esarhaddon crossed over to become policy-makers with significant influence on political decisions. 14 The view that Esarhaddon was a uniquely paranoid and superstitious individual who was manipulated by his scholars has a long history, although others have noted that he took measures to avoid being overtly manipulated or have emphasized the dependence of scholars on the king. 15 This study will apply new methodologies to answer these questions. By employing social network analysis to analyze Esarhaddon and Ashurbanipal's correspondence with their scholars, it will argue that an inner circle of nine prominenet scholars gained significant power during the final years of Esarhaddon's reign through controlling access 13 Eckart Frahm, "Royal Hermeneutics: Observations on the Commentaries from Ashurbanipal's Libraries at Nineveh," Iraq 66 : 45-50; see also Jeffrey L. Cooley, "Celestial Divination in Esarhaddon's Aššur A Inscription," Journal of the American Oriental Society 135 : 131-47. 14 Radner, "Royal Decision-Making," 272-74; Giovanni B. Lanfranchi, "Scholars and Scholarly Tradition in Neo-Assyrian Times: A Case Study," State Archives of Assyria Bulletin 3 : 99-114; Cynthia Jean, "Divination and Oracles at the Neo-Assyrian Palace: The Importance of Signs in Royal Ideology," in Divination and Interpretation of Signs in the Ancient World, ed. Amar Annus , 267-75. 15 For those scholars who entertained the idea that Esarhaddon was a uniquely paranoid monarch, see A.T. Olmstead, History of Assyria , 347; Wolfram Von Soden, Herrscher im alten Orient , 125-26; Oppenheim, "Divination and Celestial Observation," 120-21; Simo Parpola, "Assyrian Royal Inscriptions and Neo-Assyrian Letters," in Assyrian Royal Inscriptions: New Horizons in Literary, Ideological, and Historical Analysis, ed. Frederick Mario Fales , 117-42, here 123. Lorenzo Verderame has noted steps Esarhaddon took to avoid being manipulated, such as asking multiple scholars to separately give their interpretations of the same event. See Verderame, "A Glimpse into the Activities of Experts at the Assyrian Royal Court," in From Source to History: Studies on Ancient Near Eastern Worlds and Beyond Dedicated to Giovanni Battista Lanfranchi on the Occasion of His 65th Birthday on June 23, 2014, ed. Salvatore Gaspa, Alessandro Greco, Daniele Morandi Bonacossi, Simonetta Ponchia and Robert Rollinger , 713-28; Verderame, "Astronomy, Divination, and Politics in the Neo-Assyrian Empire," in Handbook of Archaeoastronomy and Ethnoastronomy, ed. C. L. N. Ruggles , 1847-53. Erle Leichty, "Esarhaddon, King of Assyria," in Civilizations of the Ancient Near East, ed. Jack M. Sasson , vol. 2, 949-58, here 957, suggested that Esarhaddon was no more paranoid than any other Assyrian king. More recently Brown, Mesopotamian Planetary Astronomy, 44-47 and Josette Elayi, Esarhaddon, King of Assyria , 43-44 have emphasized scholars' dependence on the king rather than the reverse. --- AVAR to the king through frequent substitute king rituals and warnings about auspicious days. After Esarhaddon's death in 669 BCE, the scholars of the inner circle were quickly excluded from positions of power by Ashurbanipal. This strongly suggests that the decline of court scholars in the latter half of the seventh century should be understood primarily as a political phenomenon, through which scholars who wielded power through their claim to exclusive access to an esoteric body of knowledge came to be viewed as a political threat which must be curtailed. --- Methodology Previous studies of the role played by scholars in the Assyrian court have rightly emphasized the personal relationships between the king and scholars over attempting to identify their formal position within the imperial administration. 16 This framework can be rightly extended to understanding the entire Neo-Assyrian administration: letters sent to the king by provincial governors and palace and temple officials are just as concerned with royal favor, rewards, and punishments as those of their scholarly counterparts. 17 Studies of modern organizations have shown that organizations rarely operate according to their formal hierarchy. Orders given by leaders Brown, Mesopotamian Planetary Astronomy, 42-48; Pečírková, "Divination and Politics in the Late Assyrian Empire," 158-68; Eleanor Robson, "Empirical Scholarship in the Neo-Assyrian Court," in The Empirical Dimension of Ancient Near Eastern Studies/Die empirische Dimension altorientalischer Forschungen, ed. Gebhard J. Selz , 603-29, here 607-08; Melanie M. Groß, At the Heart of an Empire: The Royal Household in the Neo-Assyrian Period , 300-02. The major exception is Parpola, "The Assyrian Cabinet," in Vom Alten Orient zum Alten Testament: Festschrift für Wolfram Freiherrn von Soden zum 85. Geburstag am 19. Juni 1993, ed. Manfried Dietrich and Oswald Loretz , 379-401; who situated scholars within a proposed 'cabinet' of eight officials which reflected a divine council of gods. Parpola's model is too rigid and includes offices which were prominent at different points in Neo-Assyrian history. are often ignored by subordinates, few members read their organization's formal regulations, and most employees find out about policy changes through their peers rather than through formal channels. Understanding power within an organization therefore requires studying informal ties rather than formal organizational structure. 18 This applies to the ancient world as well as modern corporations -the correspondence of Assyrian kings reveals many cases where officials who held formally important titles wielded little actual influence, and conversely where persons who held less prestigious offices were in fact extremely influential due to having a high trust relationship with the king. 19 Social network analysis is an especially useful tool for quantifying informal relationships within organizations. Social networks simplify relationships into a system of nodes and connecting edges, which can then be mathematically analyzed. In a communications network, nodes represent either individuals or other actors within the network. Edges represent communications sent between the nodes. Edges can connect nodes in one direction or in both directions. A path is a connection between three or more nodes which does not include any node or edge more than once. Edges can also be weighted. For this --- AVAR study, the weight of the edges corresponds with the number of communications sent between two nodes. 20 This study uses two measures to analyze the networks: Betweenness centrality and Bonacich centrality. Betweenness centrality attempts to identify which nodes serve as bridges between different parts of a network by calculating how often each node sits on a possible path between two other nodes. Nodes with a higher number of possible paths which run through them will have higher scores. 21 Betweenness centrality therefore measures which nodes have the most control over the movement of information within the network. However, betweenness centrality does not consider the weight of ties, so a node which communicates once with two separate nodes will have the same betweenness centrality as one which regularly serves as a conduit between two other nodes. Research by Karen Cook et al. has shown that betweenness centrality often failed to predict influence in networks where centrality was a zero-sum game in which gains made by one actor came at the expense of another . 22 In order to address these weaknesses, Philip Bonacich developed a measure called Beta-centrality . This measure calculates centrality by taking into account the centrality scores of other nodes when computing each node's centrality score. Every node's centrality affects the score of other actors within a certain radius. The formula for Bonacich centrality contains an attenuation factor β which can be set to any number between 1 and -1 by the analyst. The absolute value of β determines the radius within which the centrality scores of other nodes affect a certain node's score. Setting β as a positive number analyzes a network as positively connected, so that nodes gain power from being connected to influential nodes. Setting β as a negative number analyzes the network as negatively connected. 23 Absolute values of β which are closer to zero heavily weigh the immediate connections of each actor, while an absolute value of 1 takes into account scores across the entire network. 24 Because different values of β can produce extremely variable results in low density, negatively connected networks, Bonacich suggests either selecting a value for β based on an estimate of the degree of separation which affects an individual's status, or setting an extreme absolute value for β. 25 As the goal of this paper is to identify shifting power relationships between the king, scholars, and other officials, this analysis treats power and influence as a finite resource. Superiors can only give a finite amount of attention to subordinates, and so they distribute this attention unequally. Increased attention given by the king to one subordinate takes attention away from other subordinates. While studies of communications networks typically analyze their subjects as positively connected networks, in this study communications are not being analyzed in order to gauge their efficiency but as a proxy for power and influence. 26 This study therefore treats the Neo-Assyrian empire as a negatively connected --- AVAR network. I have therefore set the value of β to -1, weighting the entire network when calculating the scores of each node. Any change in the king's favor towards one official can therefore elevate or demote others. The Data I constructed the data sets 27 for this study manually, compiling networks of all extant communications which can be dated to the reigns of Esarhaddon and Ashurbanipal. To better understand changes in the networks over time, I also constructed four smaller networks consisting of letters which can be dated to the years 680-675 and 674-669 during Esarhaddon's reign and the years 669-664 and 652-646 under Ashurbanipal. Only a handful of letters from the Neo-Assyrian period contain dates, and even fewer mention the king by name. Letters must therefore be dated through a combination of prosopography, stylistic considerations, orthography, paleography, archaeological context, and historical events mentioned in the texts. 28 Letters from scholars which contain detailed reports of astronomical phenomena and can often be dated to the precise day the letter was written. 29 This data set makes use of the extensive work on dating letters which has been carried out as part of the State Archives of Assyria Project. This allows us to assign 848 letters to the reign of Esarhaddon, from his coronation on 18 or 28 Adar 681 BCE to his death on 10 Marchesvan 669 BCE. 30 As the precise dates for the end of Ashurbanipal's reign are not known, all letters from his accession in 669 until the fall of the empire 27 The data can be accessed through https://zenodo.org/records/10041178. 28 Parpola, "Assyrian Royal Inscriptions and Neo-Assyrian Letters," 126-28. 29 Parpola, Letters from Assyrian Scholars,vol. 2, The cautious scholar should note when dating texts that SAA 10 uses Julian calendar years for astronomical calculations, while SAA 8 uses astronomical years. As astronomical years contain a year '0' for mathematical purposes, astronomical years BC are numbered one year lower than the equivalent Julian years. have been analyzed as a single network containing 630 letters . An additional 530 letters, largely very brief or fragmentary examples, could date from the reigns of either Esarhaddon or Ashurbanipal and have therefore been excluded from this study. Because one of the goals of this study is to analyze the status of scholars relative to other officials in the empire, all letters dating from the relevant time frame were included in the relevant networks, not only those sent to or from scholars. I was able to considerably expand the initial data set through including what I call "developed messages." Two forms of developed messages can be recognized: the first are written or verbal communications which have been lost but are mentioned in surviving correspondence. This could include cases where a letter-writer mentions that they are replying to a previous message, where a letter summarizes other messages sent and received by the writer, or other references to previous letters and communications. Communications the writer promised to send at a later date, and unsubstantiated allegations about communications sent or received by third parties were not included as developed messages. The second form of developed message comes from co-authored letters, which are especially common among the letters from scholars and posed a special challenge for compiling this data set. Letters from co-authors were counted as a separate communication from each coauthor to the recipient. As the senders of the letter presumably communicated with each other about its contents, a bi-directional connection was added between each co-author. Messages sent to multiple recipients were counted as separate messages from the sender to each recipient, but no connections were made between the recipients as they may have read the message individually without consulting one another. The inclusion of developed messages expanded Esarhaddon's network to include 289 nodes which sent a AVAR total of 1,231 messages. The network of Ashurbanipal and later kings consists of 259 nodes which sent a total of 843 messages (Table 1 --- AVAR the same principle of disambiguating personal names discussed above: namely, that splitting individuals is less likely to distort the final conclusions than merging them. Fragmentary letters for which the sender and recipient are both unknown were not considered for the analysis; 136 letters dated from the reign of Esarhaddon and 134 from the reign of Ashurbanipal were therefore not included in the networks. Six letters from the reign of Ashurbanipal and two letters from the reign of Esarhaddon identify themselves as being written either by all the people of a city or by the ruling class of that city.33 There are also ten letters sent by kings which are addressed to an entire city or cities . 34 These letters have been accounted for by adding a single node for each city which sent or received them. Letters where governors identify themselves by name but append a demonym or city name to their greeting formulae have been counted only as messages to or from that individual governor, as this is likely a rhetorical strategy rather than indication that the letter had a larger number of authors. Has the Scholarly Correspondence of Earlier Assyrian Kings Not Yet Been Found? Any modern scholar considering whether the scholarly correspondence of Esarhaddon and Ashurbanipal is typical or exceptional is immediately confronted with the massive disparity in the number of letters from scholars which can be dated to their reigns versus the reigns of their predecessors. Out of 848 letters dating from the reign of Esarhaddon, 436 are to or from scholars . Among the 630 letters from Ashurbanipal or later kings, 106 are to or from scholars . Compare this to the 1,151 letters dating from the reign of Sargon II, of which only two were written by scholars. Only one letter from a scholar is present among the 69 which can be dated to the reign of Sennacherib, while no letters from scholars are to be found among the 188 that date from the reign of Tiglath-pileser III (r. --- 745-727 BCE). 36 The subset of letters which can be dated more precisely than to the reign of a king tend to cluster around certain date ranges. The majority of Esarhaddon's datable correspondence comes from 674 BCE or later while only sixty letters can be dated to 675 or earlier. Thirty-one letters from scholars can be dated to 675 or earlier, compared to 213 which can be dated to 674 or later. 37 Fifty-seven letters from the reign of Ashurbanipal can be dated to before 664, of which fifty were sent to or from scholars. Only twenty-three letters AVAR from scholars can be dated to Ashurbanipal's reign after 664. 38 There is also a substantial cluster of 151 letters from the years 652-646, but only fifteen of these letters were sent to or from scholars . 39 One must proceed cautiously with such statistics. Letters from scholars can be more precisely dated than letters from other officials, which means that they are over-represented in subsets of letters which can be dated to within a six-year period. If we divide the 412 letters from non-scholars to Esarhaddon by the twelve years of his reign, we return an average of 34.3 letters per year, or 206 letters for the period 674-669. This suggests the true figure for the proportion of letters to and from scholars in the final six years of Esarhaddon's reign is around 50%, the same as the earlier half of his reign and for his reign as a whole. Likewise, scholars seem have consistently written to the king in Akkadian. The dearth of letters from officials outside of Babylonia or the Assyrian heartland during the reigns of Esarhaddon and Ashurbanipal suggests that much of this correspondence must have been carried out in Aramaic written on perishable materials rather than on durable clay tablets. It is here that a close study of the archaeological context of the Nineveh letters would be of great assistance. Yet here we face the difficulties caused by half a century of destructive excavations by the British Museum at Kuyunjik. Excavators usually did not record any find spots for any of the tablets recovered, which means that the only way to recover any information about find locations is by matching museum registration numbers which indicate a year of accession with rooms of the Southwest Palace or other areas known to have been excavated during a specific season. 42 While each expedition collected surface finds all over the tell and catalogued texts found by the watchmen hired to guard the site between dig seasons, the majority of the texts which were added to the museum's collection in a certain year can be assumed to have come from the areas which were excavated that previous season. Collating this data shows there were five major locations where large numbers of letters were found ( If we accept that the letters were recovered from secondary depositions into which the surplus royal archives were discarded, the fact that Esarhaddon/Ashurbanipal letters show that scholarly correspondence made up a fairly consistent 45-55% of letters across all find spots while hardly any scholars' letters appear among the recovered correspondence of Sargon II strongly suggests that the earlier king did not correspond regularly with scholars in the same manner as Esarhaddon and Ashurbanipal. This is not to say that scholars were not present in Assyria during Sargon II's reign, only that they did not enjoy the same access to the king as they did during the the reign of these later kings. The temple appears to have been the primary employer of scholars throughout the Middle and early Neo-Assyrian periods, as it was in all periods in Babylonia. 50 Even as scholars took on an important role in crafting Sargon II's royal propaganda, Sargon appears to have kept them at arms length and did not allow them access to the inner circles of power. in both centrality measures because they either only wrote to the king or rarely or never received replies. Social network analysis allows us to refine Parpola's list. To define the inner circle more rigorously, Z-scores were computed for each node in the network. First, the mean score and standard deviation were calculated for each centrality measure. Esarhaddon and the nodes representing unidentified correspondents were excluded from these calculations. Z-scores were calculated by subtracting the mean score from each node's score and dividing the result by the standard deviation. The resulting Z-score for each node gives their centrality score in terms of number of standard deviations from the mean. Scholars whose score lies greater than one standard deviation above the mean were included in the inner circle. This allows us to define the inner circle down to ten prominent scholars, nine of whom have a Z-score greater than one in Bonacich centrality and six of whom have a Z-score greater than one in betweenness centrality . The chief scribe Issaršumu-ereš, the exorcists Adad-šumu-uṣur and Marduk-šakin-šumi, and the scholar and envoy Mar-Issar rank highly in both categories. The astrologers Balasî and Nabû-ahhe-eriba, the exorcists Nabû-naṣir and Urad-Gula, and the physician Urad-Nanaya score highly in Bonacich centrality only, while the chief scribe Nabû-zeru-lišir has a high score in betweenness centrality alone. Nabû-zeru-lišir's low Bonacich score may be due to an early death, as he does not appear in any sources after 673 and likely died that year. Only a handful of other officials have centrality scores comparable to the members of the inner circle. Those other officials with Z-scores at least a standard deviation above the mean in either centrality measure include the crown princes Ashurbanipal and Šamaš-šumu-ukin, Esarhaddon's mother Naqia, his son Šamaš-metu-uballiṭ, and a handful of palace, temple, and provincial officials. With only a handful of exceptions, scholars in the inner circle are the only ones who recommend the enthronement of a substitute king, the only ones who write letters addressing the king as 'the farmer' during a substitute king ritual, and the only ones who advise the king on auspicious and inauspicious days for receiving visitors or performing activities. 56 Many of them were blood relatives: Nabû-zeru-56 For letters concerning the enthronement of a substitute king, see SAA 10 1, 3, 189, 209, 219-221, 314, 377, ; SAA 10 25, 221, 240 ; SAA 10 1, 12, 25 ; SAA 10 350-352 ; SAA 10 25 ; SAA 10 1-3 . The only persons outside the inner circle to recommend enthronement are Urad-Ea and Nabû-šumu-iddina in SAA 10 1:3-4, where they appear as two of five co-authors alongside three members of the inner circle, and Munnabitu in SAA 8 316: r. 1-3, but note that this letter was sent in 677 BC, early in Esarhaddon's reign, and this scholar is not attested after 674 . It is possible that Munnabitu was an important scholar earlier in Esarhaddon's reign when there are fewer surviving letters. For letters sent to 'the farmer,' see SAA 10 2 ; SAA 10 26 ; SAA 10 209-212, 221 ; SAA 10 1 ; SAA 10 212 ; SAA 10 325 . In addition to the co-authored AVAR lišir and Adad-šumu-uṣur were sons of Nabû-zuqup-kenu, a prominent scribe under Sargon II and a descendant of the scribe Gabbu-ilani-ereš. Issar-šumu-ereš was the son of Nabû-zeru-lišir, while Urad-Gula was the son of Adad-šumu-uṣur. 57 Nabû-zeru-lišir and Issar-šumu-ereš also appear as Esarhaddon's scholars in the Synchronistic King List, a late seventh century list of Assyrian and Babylonian kings which also records their most prominent scholars. 58 However, scholars from the inner circle only make up one-fifth of the fifty scholars attested in Esarhaddon's correspondence. The rest form a long-tail distribution of scholars with low centrality scores . Nearly three-fourths of the scholars in the 'out-group' did not correspond with anyone other than the king, and the median number of letters this group sent was two. While all the members of the inner circle except for Mar-Issar appear to have been based in Nineveh, scholars in the outer circle identify themselves as hailing from Aššur, Arbela, Harran, Borsippa, Dilbat, Cutha, and Uruk. 59 It is not known if these scholars were writing from their hometowns or if they relocated to Nineveh to seek royal employment. In either case, scholars from the out-group were on the outside looking in, sending SAA 10 1, two additional letters to 'the farmer' from outside the inner circle are known: SAA 10 128 and SAA 13 75 . For letters advising Esarhaddon on auspicious days, see SAA 10 190:11-r. 4, 192: r. 1-9, 203:12-r. 11, 207:5-17, 221: r. 5-12, 314:3´-11´ ; SAA 10 233: r. 6-12, 253:15-r. 12, 254: r. 2-13, 260:10-r. 6 ; SAA 10 5:8-r. 6, 6: r. 11-19, 7:6-14, 13:6-15, 14:8-r. 10, 18:5-r. 9, 19:4´-r. 8 ; SAA 10 70:6-14, 73:7-r. 17, 74:6-r. 3 ; SAA 10 52:6-r. 12 ; 44:7-14; 53:10-r. 7 ; SAA 10 325: r. 3´-7´ . The lone exception, SAA 16 62:5-9, was sent by the so-called "anonymous informer." their observations to the king while receiving infrequent replies and occasional acknowledgment of their services. What did scholars in the out-group write to the king about? A survey of astronomical omen reports shows that scholars in the out-group were much more likely to report positive omens and less likely to report negative ones . Omens were classified as positive if they decreed something good for "the land" or for Subartu or Akkad. The latter two terms were equated with Assyria and Babylon by scholars, and as Esarhaddon held both crowns simultaneously omens concerning both regions were of equal relevance. 60 Omens were also classified as positive if the scholar explicitly stated they should be interpreted as positive. Scholars of the inner circle reported close to equal numbers of positive and negative omens. Scholars in the out-AVAR group, however, reported almost three times as many positive omens as negative omens. If one counts reports which contain a mixture of good and bad omens as a half negative and half positive, then scholars in the out-group reported positive omens in 69% of their reports , compared to 36% for reports from scholars in the inner circle. This is all the more surprising given that the probability of a lunar eclipse omen portending negatively for Assyria was somewhere between 50-60%, depending on the interpretive method used. 61 In short, it appears that only scholars from the inner circle had the standing to deliver bad news to the king. Scholars of lesser status sought to move into the inner circle by sending good news of the gods' continued approval of the king. --- AVAR November 3, 677 actually triggered an enthronement. 64 Although at least sixteen scholars are attested as writing to Esarhaddon during this period, not a single response of the king is recorded, nor do the scholars ever co-author letters. While one report sent by the scholar Munnabitu recommended enthroning a substitute king, his advice is contradicted by a report from another scholar, and there is no evidence that an enthronement actually took place. 65 Our first firm evidence of a substitute king being enthroned comes from letters sent by scholars from the inner circle in response to an eclipse on September 3, 674 which discuss the unfortunate substitute's time on the throne and his burial. 66 The presence of a substitute for each of the four eclipses which occurred thereafter is attested by numerous letters which discuss Esarhaddon in hiding as well as the execution and burial of the substitutes. 67 If each instance required the king to remain secluded for the full one hundred days normally required, this would mean that Esarhaddon spent more than one-fifth of his final five years as king in hiding while a substitute sat on the throne in either Assyria or Babylon. the king and Urad-Nanaya forbidding the crown princes from going outside during the ritual. 69 Attestations of the substitute king ritual are rare outside of Esarhaddon's reign. The ritual is attested as being performed twice late in the reign of Adad-nirari III sometime between 786 and 783 BCE, but is not explicitly attested anywhere else in Assyria prior to the reign of Esarhaddon. 70 The rhetorical phrase "I would go as a substitute for the king" in letter greeting formulae from Babylonia was common from the Old Babylonian period onwards, so its continued use in letters from the reign of Sargon II does not imply that the ritual was currently being practiced. 71 It seems likely that the inner circle of scholars revived a ritual which had long since fallen out of use in order to control access to the king. Likewise, auspicious days are first referenced in the royal inscriptions of Sargon II describing the founding of Dur-Šarrukin, but there is no evidence for kings prior to Esarhaddon's reign following a regimen of auspicious days which determined their movements and when they would receive visitors. AVAR multiple experts. 73 The picture of scholars during Esarhaddon's reign is therefore one in which a small group of scholars occupied positions of great power and influence, while a much larger group attempted to curry favor in hopes of someday being invited to join this inner circle. When did this situation come into being? While letters from scholars make up about half of the letters which can be dated from earlier in Esarhaddon's reign, Nabû-ahhe-eriba is the only scholar from the inner circle who appears in the earlier correspondence. 74 There are no letters describing the reign of a substitute king, nor are there any letters informing the king about auspicious days. All of these appear in the correspondence from 674 BCE onwards. We can only speculate as to what internal or external pressures caused Esarhaddon to turn towards scholars during the latter half of his reign. Esarhaddon's attitude towards scholars combined utter confidence in their methods with a measured trust of the persons employing them. Early in his reign, the scholar Bel-ušezib warned him in a letter that during the reign of his father the interpreters of astronomical omens and extispicy experts had conspired together to conceal negative omens from the king. 75 Esarhaddon's own scholars sometimes pleaded that they had not hidden any omens from the king, defending themselves against a concern Esarhaddon must have sometimes expressed. 76 His suspicions were not unfounded: as has been shown above, his more junior scholars showed a clear preference for 73 For co-authored letters from the inner circle see SAA 10 3 ; SAA 10 209, 256, 259 ; SAA 10 24 ; SAA 10 205 ; SAA 10 1 ; SAA 10 212 ; SAA 10 40-41, 43-44, 47, 50, 53 ; SAA 10 25 ; SAA 10 297 . 74 SAA 8 39. 75 SAA 10 109: r. 1-10; dated by the discussion of the events surrounding Sennacherib's assassination in ln. 7´-21´ and r. 14-15. reporting positive omens over negative ones. While Esarhaddon was probably literate, he was unlikely to have mastered the obscure signs and knowledge of the Sumerian language needed to read scholarly texts, as evidenced by the glosses which his scholars sometimes added to their reports for the king's benefit. 77 Although Esarhaddon sometimes attempted to obtain independent interpretations from his scholars and prevent them from conspiring together to agree on an interpretation, he was ultimately at his scholars' mercy when it came to understanding the complex astronomical texts from which they drew their interpretations. 78 As Balasî wrote in one letter to the king after Esarhaddon attempted to read the standard birth omen series for himself, "Šumma izbu is difficult to interpret…truly, [one] who has [not] had the meaning pointed out to him cannot hope to understand it!"79 --- Scholars and Social Networks under Ashurbanipal The network of Ashurbanipal and later kings contains 259 nodes and 412 edges containing 843 separate communications. Eleven actors in the network can be identified as temple personnel, eleven as palace personnel, six as members of the royal family, eight as tribal leaders, The network includes twenty-nine communications from the reign of Sîn-šarru-iškun, two from the reign of Aššur-uballiṭ II, thirty-six which could date from late in Ashurbanipal's reign or in the reign of a later king, and five dating to one of the kings following Ashurbanipal but which could not be dated more precisely. The network includes many private archives dating from the final fifty years of the empire, which form their own networks distinct from the main network and cause some of their members to score very highly in the Bonacich centrality measure. Letters from the western half of the empire are completely absent from Ashurbanipal's correspondence. Except for correspondence with foreign kings in Urartu, Elam, and Dilmun, all letters originate either from the Assyrian heartland or from Babylonia. Despite even narrower geographic limitations on the corpus, letters to and from scholars make up a much lower percentage of Ashurbanipal's correspondence than they did under Esarhaddon. Nearly all the scholarly correspondence from Ashurbanipal's reign dates from the 674-664 BCE cluster of letters which represents continuity from Esarhaddon's correspondence. There are only twenty-three letters from scholars which date from later than 664, and none which can be dated to the reigns of the kings who came after Ashurbanipal. 80 The latest known letter sent by a scholar was sent sometime shortly after 648 BCE.81 Whereas Esarhaddon's network features a clear 'inner circle' of scholars who have centrality scores much higher than the majority of scholars as well as other officials, there are only three scholars in Ashurbanipal's network who have a betweenness centrality score higher than zero. Only one scholar -Akkullanu -has a Z-score more than one standard deviation above the mean in betweenness centrality, and no scholar has a Bonacich centrality score above this mark. Four scholars -Akkullanu, Babu-šumu-iddina, and former inner circle members Nabû-ahhe-eriba and Issar-šumu-ereš -achieve a Bonacich score more than one standard deviation below the average, --- AVAR Only sixteen of the fifty scholars who appears by name in Esarhaddon's correspondence also appear in Ashurbanipal's letters. This is not merely a product of normal turnover: those sixteen scholars make up the majority of scholars attested by name from the reign of Ashurbanipal. The missing scholars from Esarhaddon's correspondence were mostly not replaced. Only five scholars appear by name in Ashurbanipal's letters who were not also attested in Esarhaddon's correspondence, and all of them have very low centrality scores. Of the ten scholars in Esarhaddon's inner circle, Nabû-zeru-lišir was probably deceased by the time Ashurbanipal took the throne in 669 BCE as he is not attested in any documents after 673. 82 The physician Urad-Ea, the exorcists Nabû-naṣir and Marduk-šakin-šumi, and the scholar Mar-Issar also do not appear in Ashurbanipal's correspondence. To compare centrality scores in networks of different sizes, scores must first be normalized by dividing each score by the maximum possible score for that network. Comparing normalized scores from the reigns of Esarhaddon and Ashurbanipal shows that nearly every scholar with a Bonacich or betweenness score higher than zero experienced a decline in centrality scores of 75% or more . The one exception is Akkullanu, a scholar of little importance during Esarhaddon's reign who rose to become the only scholar of any appreciable centrality during the reign of Ashurbanipal. This decline is especially striking among the five remaining members of the inner circle, who all exhibit sharp declines in centrality measures relative to both to the positions which they held under Esarhaddon and to other persons in Ashurbanipal's network . For reasons outlined above, comparisons across the 6-year subset networks must be done with caution, due to both the small sample size and the fact that letters from scholars are more likely to be dated with precision. The smaller sample sizes and the removal of most of the non-scholarly correspondence from the networks spanning 674-664 combine to have a major distorting effect on complex centrality measures such as the Bonacich measure. Nevertheless, while scholars account for the vast majority of the letters which can be dated to Ashurbanipal's early years from 669-664, few of them connect to anyone besides the king. In sharp contrast to the final years of Esarhaddon, only one co-authored letter is evident, and of the thirteen scholars in this network only Akkullanu connects with anyone other than the king or a co-author. 83 With the exception of Balasî, who coauthored a letter to Ashurbanial with the astrologer Bamaya, none of the scholars of the inner circle communicate with anyone other than the king. --- AVAR connected to other actors changes from Esarhaddon to Ashurbanipal. Under Esarhaddon, Adad-šumu-uṣur sent messages to twelve other actors while receiving messages from eleven. His nephew Issar-šumuereš sent messages to twelve and received messages from thirteen. Under Ashurbanipal, Issar-šumu-ereš sent messages to two actors and received messages only from the king, while Adad-šumu-uṣur corresponded with the king only. Other persons no longer saw these scholars as persons of influence through whom they could connect to the king. Scholars from the inner circle also no longer co-authored letters in the same way they did under Esarhaddon. Only one scholar managed to increase his centrality score under Ashurbanipal: the scholar Akkullanu, who had been of little consequence under Esarhaddon, managed to maintain an unusually long career under Ashurbanipal, corresponding with the king into the 650s. 85 However, Akkullanu scores very low in the Bonacich centrality measure, suggesting his status was highly dependent on the king. Overall, the picture which social network analysis reveals is that under Ashurbanipal the status of scholars in the inner circle declined to a level similar to that of scholars in the out-group under Esarhaddon, while scholars from the out-group largely ceased to write to the king altogether. Presumably, after hearing of the decline in status of the inner circle many of them lost hope that the new king would reward them, and so returned to the temples to continue their work there. A few new scholars appear in Ashurbanipal's later letters, but most scholars ceased to write to the king and were not replaced. --- AVAR A qirsu was a portable tent shrine used to perform aspects of various rituals, including the substitute king ritual. 89 The secrecy surrounding these reports could only have increased the control which the scholars of the inner circle maintained over Esarhaddon. While the eclipse of 667 did not call for the enthronement of a substitute, Ashurbanipal clearly had no intention of continuing his father's practice of receiving reports in secret. The tensions between Ashurbanipal and his scholars became more apparent a year later, when a partial lunar eclipse occurred in conjunction with Jupiter on April 10, 666 BCE . This portended evil for Subartu and that an important person would die in the place of the king. 90 Ashurbanipal responded to his scholars' recommendations by doing nothing for several months, even though the sartinnu died within a month of the eclipse. 91 Eighty-six days into the one-hundred-day period specified by lunar eclipse omens, Akkullanu finally sent a sharply-worded letter asking "why is nothing being done month after month? [It] is a crime! Something will come of it!" 92 Akkullanu recommended that Ashurbanipal confine himself to the palace while the ritual "Giving a Person's Substitute to Ereškigal" was performed. 93 Ashurbanipal instead enthroned an inanimate statue as a substitute in Akkad, but did not reply to Akkullanu's letter or inform him of this decision until after the ritual had been completed. 94 Akkullanu was furious, writing a lengthy letter castigating the king for enthroning a substitute in Akkad where it would protect Šamaš-šumuukin rather than himself. He couched his criticism as protecting the king's best interests, saying "if I had not talked to the king my lord today, in the morning would the king not say to his servant: 'You were a servant of my father, why did you not advise and explain to me?'" 95 He further suggested the king may have been poorly advised by other scholars. 96 Yet Ashurbanipal had studied the omen corpora himself when crown prince, and may have known that eclipses in the month of Nisan were usually taken to pertain to Akkad, as were eclipses which occurred in the evening. The eclipse of April 10 moved from left to right across the lower part of the moon, exiting in the quadrant which some interpretive schemes associated with Akkad. 97 It is entirely possible that Ashurbanipal pursued his own interpretation of the omen and chose a course of action at odds with the recommendations of his scholars -one which did not require him to isolate himself. Ashurbanipal's choice to use an inanimate statue rather than a live human as a substitute king represented a departure from normal practice under Esarhaddon, although it was not unprecedented in Assyrian rituals. 98 In fact, despite the occurrence AVAR of several solar eclipses as well as a great number of lunar eclipses during his reign, some of which portended evil for Subartu, only two substitutions rituals are attested as being carried out under Ashurbanipal. There is no evidence that Ashurbanipal ever carried out a substitute king ritual using a live human being. 99 The only other text possibly referencing a substitution ritual from his reign is an anonymous ritual instruction addressed to 'the farmer' which describes a helical rising of Mars in Aries that could only have occurred on April 18, 689 or May 4, 657 BCE. 100 Parpola preferred the latter date as a solar eclipse had occurred only nineteen days prior, but another solar eclipse had occurred ninety-eight days prior to the April 689 rising, and it is possible that the rituals were intended to close out the king's term as a substitute. In any case, the type of substitute is not mentioned, and it is possible that this ritual was also carried out using an inanimate image. Ashurbanipal also does not seem to have consulted his scholars about evil or auspicious days, as this topic is conspicuously absent from his correspondence compared to the letters between scholars and Esarhaddon. It would be inaccurate to say that Ashurbanipal completely disregarded his scholars' expertise. He occasionally wrote to them inquiring about observations of expected lunar eclipses, earthquakes, or purification rituals. 101 But by disregarding their advice on substitute kings and auspicious days, he ensured that scholars no longer had the ability to control his movements or dictate who was allowed to be admitted into his presence. Nowhere was the decline in status of scholars in the inner circle felt more acutely than in the Gabbu-ilani-ereš family. Even before he became king, Ashurbanipal had refused to hire Nabû-zeru-lišir's son Šumaya even even as the younger scholar was struggling to pay off his father's accumulated debts. AVAR that he had either died or sold off his personal library, which by this date was incorporated into Ashurbanipal's library at Nineveh. 115 A lone scholar stands out amidst the declining centrality of scholars in Ashurbanipal's social network. Akkullanu is the only scholar whose betweenness centrality rises one standard deviation above the mean . During Esarhaddon's reign he had been a scholar of no particular importance who sent reports of mostly negative omens to the king . Under Ashurbanipal he became the king's preferred scholar, regularly fielding inquiries about rituals, temple administration, and copying texts for Ashurbanipal's royal library. 116 His later omen reports to Ashurbanipal suggest that he changed his approach. During the conflict with the Cimmerians in 657 BCE, Akkullanu authored a long omen interpretation which went to great lengths to spin negative omens into assurances of Assyrian victory, even quoting a now-lost Middle Babylonian literary letter to argue that a recent drought represented a positive omen as it would encourage Assyria's soldiers to fight harder in order to secure food for themselves. 117 In another report, he predicted that a solar eclipse would augur poorly for the king of Elam. 118 Yet, Akkullanu had a base of support outside of the palace: he was a priest in the temple of Aššur, and many of his connections in Ashurbanipal's network were to priests or other temple personnel with whom he interacted during the course of his duties. 119 He was AVAR administrative texts which are common from the final three and a half decades of the empire is a powerful argument for their decline. Only three scholars appear in legal texts dating from after 648 BCE: Urad-Nabû the doctor appears as a witness to a real estate sale from *630 BCE, while an exorcist named […]-nadin-apli and an extisipicy expert named Bel-naṣir appear as witnesses to a sale document from *621. 126 Of the three, Bel-naṣir is described as working for the crown prince, while […]-nadin-apli is in the employ of Aššur-šumu-ibni, a person about whom nothing else is known. None are described as working for the king. Conclusions: Scholarship as a Political Phenomenon In her recent book Ancient Knowledge Networks, Eleanor Robson argued that the decline of court scholars in Assyria came about as the result of an economic crisis in the aftermath of the 652-646 BCE war with Šamaššumu-ukin and Elam, which left the Assyrian kings unable to afford to pay large numbers of scholars. 127 However, the decline in centrality of scholars from Esarhaddon to Ashurbanipal which is evident in both the aggregate networks and between the 674-669 and 669-664 networks suggests that the decline in their status was immediate and took place as soon as Ashurbanipal took the throne. This is supported by numerous letters which suggest that scholars, especially those from the Gabbu-ilani-ereš family and others who had been part of Esarhaddon's inner circle, were no longer accorded the status they had previously held. Ashurbanipal did not immediately do away with the scholars, some of whom continued to serve in their positions until at least 650 BCE. But he reduced their numbers, excluded them from the inner circles of power, and did not allow them to control access to his person or 126 SAA 14 35: r. 15 ; SAA 14 166: r. 4-6 . 127 Robson, Ancient Knowledge Networks, 82-86. restrict his movements with substitute king rituals or a regimen of auspicious days. These decisions would have reduced their influence by removing the tools which the inner circle of scholars had used to control the previous king. It would be wrong to conclude that Ashurbanipal, a king otherwise famous for his scholarly learning who began to assemble a personal library of scholarly texts while still a crown prince, disbelieved in the basic premises of divination and the cuneiform omen tradition. Rather, his problem was one of power and control. The decline and fall of the Assyrian court scholar should be understood as an essentially political phenomenon. Under Esarhaddon, a small group of scholars had risen to become some of the most powerful men in the empire, who used their scholarly knowledge to achieve a certain level of control over the king himself. Ashurbanipal found this situation intolerable, and saw the scholars as a political group whose power needed to be curtailed. Ashurbanipal had been trained in cuneiform scholarship by Balasî, a member of his father's inner circle. 128 He collected a large number of omen texts himself, including the series Barûtu and Enūma Anu Enlil commonly cited by scholars. 129 Some of these texts formerly belonged to members of the Gabbu-ilani-ereš family. 130 In contrast to his father, whose basic literacy skills were not sufficient for interpreting scholarly when his scholars are stumped, while the more explicitly hostile Verse Account mocks Nabonidus for his pretentions of competence at interpreting astronomical and liver omens. 136 Both texts may represent disapproving memories among scholars of a king who overrode their expertise and did not allow them to overly influence his decisionmaking. 137 Under Achaemenid rule scholars worked exclusively for the temple, where they sometimes performed rituals to avert evil from the king without the king's knowledge. However, there is no evidence that Persian kings took notice of these performances. Scholars turned toward providing private horoscopes rather than advising kings. 138 In the latter half of the first millennium BCE, the temples of southern Mesopotamia served as arks preserving the traditions of cuneiform knowledge in a world which had moved on, but the court scholars had long since been marginalized from political power from the beginning of the reign of Ashurbanipal. --- 131 In doing so, he empowered himself to critically assess his scholars' recommendations and make his own decisions about the proper course of action in response to omens. 132 In doing so, he undermined the source of their power, that is, their ability to provide exclusive access to an esoteric body of knowledge. Having been ejected from the inner circles of power, cuneiform scholars retreated into the temple. They would remain there until the end of cuneiform writing. There is little evidence for a close relationship between Neo-Babylonian kings and their scholars. Nebuchadnezzar II asked the Eanna temple in Uruk to send lamentation priests for a ritual, implying that these scholars were primarily employed by the temple. 133 Royal inscriptions from throughout the Neo-Babylonian period also describe scholars being consulted for rituals associated with temple or ziggurat construction. 134 The royal inscriptions of Nabonidus frequently reference omens and auspicious days for beginning the construction of temples, often claiming to have performed extispicies himself. In one case he simply claims to have dreamed the appropriate astronomical omens into existence.

Modern scholars have long been divided over whether the correspondence of ancient scholars with the Assyrian kings Esarhaddon and Ashurbanipal represents an anomaly or a typical relationship between scholars and kings in the ancient Near East. This article uses social network analysis to examine the changing status of scholars in Assyria. It argues that the reign of Esarhaddon saw the emergence of an 'inner circle' of scholars who maintained power and influence through controlling access to the king, and an out-group with little influence who hoped to move into the inner circle. By contrast, under Ashurbanipal all scholars experienced an immediate decline in centrality scores, suggesting a sudden loss of status as the scholars were marginalized and slowly phased out even as Ashurbanipal collected his own archive of cuneiform scholarship. The decline of court scholars in Assyria should therefore be understood primarily as a political phenomenon, that is, an attempt by Ashurbanipal to reduce the influence of a group which he perceived as having become too powerful within the Assyrian imperial administration.

Introduction In recent years, people around the world are increasingly experiencing the effects of climate change in the form of extreme events such as devastating floods, storms, droughts and fires. While the long-standing problems of global warming and glacier melting were probably perceived as "far away" because the latter occurred mainly in remote places on the planet or the former originated in the atmosphere, the rapid acceleration of extreme events in industrialised countries has demonstrated the seriousness of the current environmental situation, exacerbated by the global energy, economic and food crisis and triggered by an unexpected conflict in Europe's neighbouring countries. All these events may have served as triggers for climate activism and the collective mobilisation of citizens. More than adults, young people have raised the demand for more effective and urgent intervention by policy makers to protect the planet and have become protagonists of a global protest movement that has quickly captured the attention of public opinion. This movement is called Fridays for Future , after the day of the first global school strike in March 2019, which involved 1.6 million protesters worldwide . Some months later, in September 2019, 7.6 million participants took part in the third global FFF Day of Protest for Climate Justice, and the strikes continue each year, leading de Moor et al. ) to call the FFF movement the largest globally coordinated climate protest in world history ). Youth are aware that they are the generation who will inhabit a planet that is already sick and whose situation is inevitably deteriorating. They protest against the negative externalities of economic development and believe that they are the main victims of the rise in temperature, water and air pollution caused by the unsustainable production of goods and consumerism responsible for the overconsumption and waste of natural resources. They are ready to fight for their right to a healthier and sustainable future and to make their voices heard to raise public awareness of this issue. They want to shake up those who still believe that environmental problems are far away from them, are not really addressed by them and therefore do not feel the need to incorporate ecological practises into their lifestyles . To investigate young people's engagement with the dangerous effects of climate change, a survey was conducted in February 2020 among 1,138 high school students in Southern Italy who were interviewed via an online questionnaire. The research question was based on investigating awareness of the main environmental issues, their opinion on the environmental plans of local authorities and whether students were willing to make a paradigm shift based on concrete actions that can reduce or stop the waste of natural resources and the pollution of the planet. Based on these premises, they committed to sharing the goals of the FFF movement, actively participating in the strikes and making a positive contribution through everyday environmental practises. To perform the statistical analysis, we used a tree-based method since, in our opinion, it is easier to interpret. For example, using a classical model such as POM , 1 3 Perceived climate change risk and global green activism among… we get as many coefficients as there are categories for both the response variable and the predictors, all of them minus 1. The latter, applied to our data, would return 57 regression coefficients for the additive model only. In this case, interpretation is difficult and we find that the classification tree for ordinal responses is much more interpretable when a data set contains many categorical variables with many categories. In our analysis, we applied an ordinal classification tree with the original impurity measure proposed by Morrone et al. . The novelty of the ordinal tree methodology used in this paper allows for better discrimination of paths when the response variable is ordinal with a cut-off value that separates ordinal categories with a positive semantic meaning from those with a negative one. The results of the study could be of interest to policy makers to understand how young people see their future from a sustainable perspective and to what extent they are ready to support the ecological transformation of public services provided to citizens. At a time when European countries need to put into practice the strategic guidelines to achieve the Sustainable Development Goals SDGs of the UN agenda , this study could be a contribution that gives some suggestions to public administrators and policy makers. It is not trivial to mention that the Italian government has put almost 250 billion euros in the reconstruction plan after COVID-19, the so-called National Recovery Plan , to carry out projects and initiatives that will influence the destiny of the country not only towards repairing the damage caused by the COVID-19 pandemic but, above all, to leave a more sustainable country for the next generation. Among the six missions of the PNNR, the green revolution, ecological transition and sustainable mobility infrastructures occupy an important place. Great attention will be paid to supporting young people and the south of Italy, traditionally poorer than the north, which will receive more than 50% of the infrastructure budget to reduce the mobility gap . The paper is organized as follows: Sect. 2 reviews the literature. In Sect. 3, we illustrate the survey on the perception of environmental risks in young people and their means of reaction. In Sect. 4, we describe and formalise the statistical methods used for the data analysis. The main results are illustrated in Sect. 5. The paper ends by summing up the results and discussing our main remarks. --- Climate activism and mitigation strategies Climate change activism has been discussed by scholars from different angles. Roser-Renouf et al. addressed the question of cognitive and affective underpinnings to understand the genesis of climate change activism. Kleres and Wettergren , seeking to understand how core emotions influence activists' motivations and mobilisation strategies, showed that fear plays a key role in raising awareness of the dangerousness of climate catastrophes and that hope drives collective movements, sharing the theme theorised by Nairn . O'Brien et al. explored youth activism on climate change by arguing about dutiful, disruptive and dangerous dissent, three different types of behaviours that can be adopted by young people, and, following Corner et al. , they expressed concern that their personal engagement may decrease if young people perceive their self-efficacy as limited. Fisher and Nasrin debated on a specific form of activism called civic engagement, a form of activism aimed to pressure different kinds of actors who might address the issue of climate change by adopting different tactics. In particular, they argued a different level of commitment depending on actors: citizens participating to influence communities, politicians and businesses can directly engage in lifestyle change by modifying their individual behaviour and consumption patterns . There are still a few studies that look at the direct effects of participation in green activism movements on changes in resource consumption ). According to Fisher and Nasrin , it is also important to distinguish between direct and indirect pathways to achieve positive impacts on climate change by putting pressure on policy makers and companies to take emission-reducing measures. The direct pathway can be chosen simply through the adoption of the above-mentioned ecological behaviours by individuals. The other way works at a higher level by asking government policies to take into account the suggestions of scientists, and this is for example the strategy followed by international environmental non-governmental organisations . Some scholars have discussed the special roles that the economic sector and businesses can play. In this case, people's civic engagement has declined in the form of shareholder activism, which focuses on dissatisfied investors who, as shareholders, have the power to put pressure on the company to move towards social responsibility and environmental corporate activities and performance . Companies give due consideration to the expectations of their shareholders to address these issues in their strategic social responsibility documents . Specifically related to the issue of the impact of people's actions in addressing climate change, a growing body of literature has addressed climate change mitigation strategies, the pathways of which can be expressed through three main climate approaches . The first approach addresses conventional climate mitigation efforts that use decarbonisation technologies capable of reducing CO2 emissions, namely renewables, fuel switching, efficiency improvements, nuclear energy and carbon capture, storage and use . The second direction addresses a newer set of technologies and methods that can be implemented to capture CO2 from the atmosphere, referred to as negative emission technologies. They are based, for example, on methods for removing pollutants, storing bioenergy, increasing the alkalinity of the oceans, sequestering carbon in the soil, facilitating deforestation and reforestation . The last 1 3 Perceived climate change risk and global green activism among… direction of mitigation strategies is perhaps the most specialised, as it deals with extremely advanced technologies whose goal is to lower temperatures without altering greenhouse gas concentrations in the atmosphere . However, as Lawrence et al. affirmed, the latter techniques are still theoretical in nature and cannot currently be included in policy frameworks. In this framework, which focuses on mitigation strategies that lie in the possibility of people's intervention, it is interesting to consider two levels of intervention: the collective level, as a city, and the individual level, as an individual citizen-activist. They comprise more than half of the world's population and are consequently responsible for three-quarters of global energy consumption and greenhouse gases . Many urban climate policies have been adopted to address climate change. The most important are improving energy efficiency, reducing fossil energy consumption and finding appropriate low-carbon development routes for sustainable development. All public organisations, especially local and regional authorities, need to clearly communicate their plans for environmental protection to improve citizens' commitment to collective and synergistic action. From our point of view, it is interesting to understand the extent to which young people are informed about the policies and actions of local authorities and whether they feel committed as part of the community or as individuals. Based on the aims of our study, this difference is not trivial, as they could belong to at least two main profiles of young citizens. The first considers the community as a kind of "shield" in which other citizens work to achieve environmental goals; the second firmly believes that his or her own actions have a strong positive impact and are a necessary seed for the spread of ecological behaviours for a more sustainable future of the planet. The issue of young people's climate activism has been increasingly discussed by scholars in recent years. De Moor et al. defined two recent movements, FFF and Extinction Rebellion , as "new" forms of climate activism because they had the power to inject new energy into global climate politics. To study the phenomenon in depth, they compared these movements with previous climate campaigns and found that the participants had some elements in common, while the main difference was the use of a more politically "neutral" framing of climate change. Recent studies have focused on the FFF movement and have made interesting contributions to knowledge about the phenomenon, social base and strategic choices of European youth , the communicative power of youth activism and crossing crises . In particular, della Porta and Portos addressed the background of protesters as a possible trigger for an active role, noting that their social composition is heterogeneous, as there is a cross-class coalition that forms the collective mobilisation against climate change. In particular, social background may influence their opinions, as demonstrators from the upper class are more likely to believe that governments and corporations are capable of solving environmental problems than activists from the working and middle classes. Eide and Kurnelius focused on the ability of FFF activists to build an identity based on scientific evidence that strengthens their authority among climate policy actors. They are defined as new ambassadors for climate action who use networked communication tools to link personal experiences and add value to climate science. We believe that this could help encourage young people to engage in genuinely pro-environmental behaviour, and it is in line with de Moor et al. , who argued that many FFF demonstrators who turned out to be students embodied the belief that the climate crisis can be solved by individuals taking responsibility, and called on policymakers to address global warming on the basis of some kind of intergenerational justice. Taking into account the recent literature on the subject, and with the aim of further contributing to the knowledge of the phenomenon, the basic idea of this study is to understand to what extent the only desirable scenario for a sustainable future is that citizens, together with businesses and policy makers, are willing to adopt environmentally friendly practises, even if they are more costly from a purely economic point of view or more demanding in terms of social behaviour. This can be illustrated in particular by the aim of understanding whether young people are willing to participate in strikes represented here by the FFF movement to defend the planet and adopt green practices as a way of life. In this way we can identify and compare their claimed principles with actual daily engagement. In such a globalised society, young people are most concerned about climate change and know its consequences, regardless of where they will occur on the planet, because they are its future inhabitants. --- A survey of young people's perceptions of environmental risks and their climate activism To discover how young people perceive the main risks of climate change and whether they are taking action to address the vulnerable impacts in their future, a survey was conducted in February 2020 among students and teachers in Puglia, a region in Southern Italy. Student participation consisted of completing an anonymous online questionnaire for which formal privacy consent was obtained. The respondents belonged to Apulian high schools participating in the National Project for a Scientific Degree in Statistics , sponsored year after year by the Ministry of Education and Research. The schools participating in the PLS program signed an agreement with the Italian universities concerned with carrying out activities that promote the acquisition of scientific and statistical skills that are more in demand in the labour market. In particular, this work draws on the experience of the University of Bari, which is one of the 14 Italian universities currently participating in the PLS and has been doing so since the 2010-2011 academic year . The PLS targeted a large number of high school students participating in the 2019-2020 PLS Project for Statistics. The respondents were surveyed using an online questionnaire containing 32 questions divided into four sections: I. Sociodemographic information 2. Knowledge and awareness of environmental issues 3. Perception of environmental risks due to climate change. 4. Environmental awareness and agreement with the principles of the FFF 1 3 Perceived climate change risk and global green activism among… movement. The respondents were asked to express their responses by selecting a few options or more frequently by rating their responses on a five-point Likert scale , with 1 being the lowest, 5 being the highest, and 3 being neutral. A total of 1,793 questionnaires were collected, but 395 records were deleted during the cleaning and preparation data phase because they were not completed or proved unreliable or the response variable was missing; 260 questionnaires completed by adults were not considered for analysis because this group did not fulfil the aims of the study. The final data frame contained 1,138 records and a subgroup of variables of interest were selected from a larger number, considering the responses that most closely matched the characteristics of the region of residence's exposure to climate change impacts. As shown in Table A1 , the students surveyed were almost evenly distributed by gender . Their mean age was 15.9 years . In the year in which the survey was conducted, they were representative in terms of age and gender, as the proportion of female Southern Italian students to the total number of female Southern Italian students was 48.3% and the corresponding proportion of male Southern Italian students was 51.6%. Overall, female and male Southern Italian students represented 26.1% and 26.2% of Italian high school students, respectively . Table A1 also shows the percentage distribution of the variables analysed in the decision tree. From the data collected, more than 89.6% of the respondents believe that FFF can be effective in combating the destruction of the planet and has achieved important results, such as a slight reduction in environmental problems , a global resonance to environmental issues , and a call to policy makers around the world to take concrete action for greater sustainability . Although the respondents showed a high level of commitment to and support for the principles of the FFF movement, only five out of 100 played an active role in environmental associations. In addition, the respondents believe they are well informed about environmental issues and are concerned about the various risks posed by climate change . Although they do not believe they live in a geographic area exposed to the most extreme phenomena, they see their country as moderately to highly vulnerable to climate change and its associated risks, especially extreme temperatures. Strong environmental awareness is demonstrated by the adoption of ecological behaviours such as recycling, reducing waste and plastic consumption, using organic products and using public transport, bicycles and electric scooters. Students participating in FFF strikes often show an even higher rate of adoption of these ecological best practices. --- Methodology In line with the aims of the study, the preliminary exploratory analysis allowed us to identify the distributions of the variables of interest. We hypothesized that young people who participate in the strikes of the FFF movement because they see their future in danger consistently adopt ecological practices as a lifestyle. To understand the factors that influence participation in FFF movement strikes, regressionlike techniques could be used, but parametric methods do not always produce the expected results. On the contrary, data mining techniques based on recursion, averaging, and randomization are able to discover hidden paths and build better predictive models. We have a set of 22 predictors that are ordinal and nominal variables, and the response variable is measured on an ordinal scale. To examine the factors that affect the climate activism, we used a tree-based method based on the classification and regression tree proposed by Brieman but modified for ordinal response variables. --- Classification tree in brief A classification tree identifies the relationships between a response variable, Y, and a set of predictor variables . In particular, a classification tree is a binary segmentation procedure of the data matrix to generate many more informative subpartitions. In our opinion the use of a tree-based method instead of a linear model is more effective because Ordinary Least Squares-based regressions return one type of best fit to the data, namely a straightline combination of the independent variables in a higher-dimensional space. Moreover, the classification tree approach is chosen among the most commonly used supervised machine learning algorithms apt to cope with a categorical target, as the flexibility and robustness it offers to analyse such kind of data, a strong tolerance to missing responses and the absence of strict constraints in terms of distributional assumptions about the data-along with the intrinsic capability of addressing in an easy way interaction, nonlinear effects, and causal priorities-coupled with the possibility of attaining a high degree of interpretability of the classification rules, makes it a very good candidate for an explorative approach to our data . Tree-based methods are often used in data mining contexts with large datasets to study, such as social science surveys. For an extensive introduction to tree-based methods, we refer to Breiman et al and Hastie et al. . --- Tree-based methods for ordinal response variables To take into account the ordinal nature of the response variable, Piccarreta suggested adopting of a new impurity measure based on the dispersion for ordinal data defined by Gini : where F Y = P. D = 2 h-1 ∑ F Y 1 -F Y i=1 1 3 Perceived climate change risk and global green activism among… The proposal was originally implemented in an R package by Archer and was then revised and technically corrected by Galimberti et al. in a new freely available R package named rpartScore. Nonetheless, the formulation in Eq. 1 does not fit the case of an ordinal variable such as, for example, satisfaction, because we believe that the scale used to measure it has an implicit crisp cut point, which separates ratings or scores expressed by people judging themselves as satisfied from ratings or scores referred to those who are unsatisfied. In our specific case, the response variable spans over 5 ordered categories , and in our opinion, an interviewee can be considered an active participant in FFF movement strikes if their score is higher than 3 . Therefore, the threshold equal to 3 is considered the cut-point that identifies an active participant in FFF movement strikes in our opinion. To explain with an example how to choose a suitable impurity measure for the case at hand, let us consider the following Table 1, summarizing five hypothetical frequency distributions of this response variable: It is worth noting that neither calculating the normalised diversity index of Gini for the five artificial distributions in Table 1 D1 , D2 , D3 , D4 and D5 -nor adopting the ordinal Gini formulation by Piccarreta -D1 , D2 , D3 , D4 and D5 -results reflected in a good choice; both formulas fail to address the substantial difference that we would see reflected in the impurity function related to a peculiar case like D4 with respect to D2 or D3. Therefore, some of the authors proposed an ad hoc formulation of the impurity function , based on weighting the differences among the ratings/scores on the two sides of the crisp threshold between an active participant in FFF movement strikes and a non-active participant, so that the impurity measure used leads to nodes where the separation between active participants in FFF movement strikes and not active ones is maximised when pursuing splits. The formula for obtaining our modified Gini impurity is as follows: where the weights w i are defined as -1 if y i ≤ y * and 1 otherwise, and the sum is taken over the scores that have a non zero frequency only (as can be easily obtained HI = H norm × h ∑ i=2 | | | w i y i -w y | | | * sign f y i ⋅ f y i-1 Table 1 Artificial distributions used to evaluate the impurity function y i 1 2 3 4 5 D1 1/2 0 0 0 1/2 D2 1/2 1/2 0 0 0 D3 0 0 0 1/2 1/2 D4 0 0 1/2 1/2 0 D5 1/5 1/5 1/5 1/5 1/5 by means of the signum function, being sign f y i ⋅ f y i-1 = 1 if f y i ⋅ f y i-1 > 0 and 0 if at least one of the involved frequencies is null) and H norm is the usual normalized Gini index: h× � 1- ∑ h i=1 f 2 y i � . This choice enables discriminating the relevant cases as D4, as the following values can show: by setting y * = 3, our index applied to the distributions shown in Table 1, returns the values 3.750, 0.625, 0.625, 4.375 and 10.000 for D1, D2, D3, D4 and D5, respectively. This aptly targets the objective of penalizing potential splits where the frequencies peak around the threshold y * , since these splits would produce children nodes in which active and non-active participants are mixed together. For more details about the proprieties of the corrected Gini diversity index for ordinal categorical variables, we refer to Morrone et al. . --- The Random Forest method The Random Forest method is a widely used approach for classification and regression . In brief, RF is an iterative process that builds a set of classification or regression trees using bootstrap samples iteratively drawn from the original learning data set. Observations not used to construct a tree are termed out-of-bag observations for that tree. To reduce the correlation between the trees in the forest, each split in each tree was identified by using the best among a subset of predictors randomly chosen at that node. RF was used to further harness the informative value in our data, by strengthening the identification of influent variables via resampling. Instead of resorting to the ensemble method for prediction -something we are not interested in at this stage -we exploit RF as a tool to rank variables based on their ability to predict the response which is assessed by variable importance measures . Given an error measure M , VIM is defined as: where ntree is the total number of trees in the forest. MP tj denotes the error of the t tree when predicting all observations that are out-of-bag for tree t after randomly permuting the values of the j-th predictor variable. M tj indicates the above-mentioned error of tree t before permuting the values of the j-th predictor variable. The RF method has the same advantages: it is not parametric, since no specific distribution of the response variable is assumed and does not require any specification of the type of relationship between the response variable and the predictors. Moreover, it provides results for a more robust assessment of the importance of the variable compared to classical tree-based methods. We used RF only to conduct a variables importance study and not to obtain the minimum prediction error. For a review of RF methodology, we refer to Breiman and Boulesteix et al. . VIM M j = 1 ntree ntree ∑ t=1 MP tj -M tj 1 3 Perceived climate change risk and global green activism among… --- Data analysis and results The ordinal classification tree was used to examine the relationship between the decision to participate in the FFF protest movement, caused by the perception of being at risk from climate change and several variables, such as: perception of being exposed to the main consequences of climate change , individual level of information, ecological practises carried out on a daily basis to respond to environmental degradation and, finally, commitment to the principles and achievements of the green FFF movement. Table 2 shows the 22 predictors that we believe influence young people's decision to take action to improve the environmental situation at risk. Data analysis was conducted with our own software written in R language on a computer with an Intel Core i7 quad-core processor . The dataset was randomly split into a "learning" set and a "test" set, with dimensions of 800 and 338 statistical units, respectively. The decision tree was selected via cross validation and the test set was used to estimate the prediction error in the tree pruning procedure . The minimum cross-validation error does not correspond to the minimum test set error, which would suggest a decision tree with 12 leaves. We chose the most conservative decision tree, which, in any case, confirms the interpretation of the phenomenon. The selected decision tree has L = 9 terminal nodes . The cross-validation prediction error is equal to 0.5930 and the corresponding prediction error computed on the test set is equal to 0.5917. The tree graph allowed us to produce a partition of the sample of individuals into groups following the interactions between the predictors and the dependent variable . Key information about each node is summarised in Table 3. The Perception of being exposed to extreme temperatures as one of the most frightening results of climate change is the first split and separates the left side of the tree, with 51.1% of students who are from "not at all" to "somewhat" concerned about it, from the right one, where we find the students who considered themselves to be at a very high risk of experiencing extreme temperatures . The tree in Fig. 2 shows the role of predictors in the decision to protest by participating in the FFF movement and to obtain the composition of the corresponding subgroups of student respondents. The tree has 9 terminal nodes and 8 splits corresponding to the following variables: TMPEXT, FFFCCC, TORN, FFFRES, LEVINF, EXTPH and STOSU. The information on the terminal nodes can be better assessed by examining the distribution of the variable FFF protest participation in each of them . Moreover, to obtain detailed information about the specific factors that trigger the FFFPRT response, it is interesting to analyse the pathways to the terminal nodes. The first split is defined by the level of concern about experiencing extreme temperatures so that on the left side are students who have a medium to low concern and on the right are those who are highly scared. Following the path in this branch, we find respondents who believe that participation in the movement is important and that the positive contribution of the FFF movement is to fight environmental degradation by raising people's awareness. A detailed analysis of terminal nodes number 4 and number 5 allows us to understand the combined effect of not being too scared about extreme temperatures exposition and to believe that FFF movement is able to produce effective results in contrasting climate change. On the right side of the tree are respondents who are generally very concerned about the risk of being exposed not only to extreme temperatures, but also to other dangerous effects of climate change related to the physical and orographic characteristics of the area in which they live. This concern is closely related to an equally strong commitment to the results achieved by the green movement protest. In fact, the modal values of the response variables in the final nodes range Perceived climate change risk and global green activism among… between 4 and 5, indicating a high commitment to protest events in defence of the planet, as shown by all the terminal nodes created by the split at internal node number 3. In particular, splitting at internal node number 6 separates students who perceive extreme temperatures, tornadoes, and storm surges as serious threats , and who view the FFF's main outcome as a call for policymakers to take concrete action on sustainability, from those who focus on the remaining options. Returning to the main path leading to the top of the tree, other triggering factors seemed to additionally characterise the students interviewed. They strongly believe in the effectiveness of protest actions and have a medium level of information, but the split in node 24 highlights the respondents who consider themselves very well informed about environmental issues and see storm surges as the most likely feared impact of climate change occurring in their neighbourhood, which is not considered to be affected by extreme phenomena anyway. The pathway leading to nodes 48, 99, 196 and 197 describes students who believe that the FFF is capable of drawing public attention to environmental problems and is thus an effective tool to reduce the destruction of the planet by raising people's awareness. This is consistent with the literature, as recent research reports that emotions such as fear and anger can trigger positive action on climate change . It is worth noting that the impact of potential risks emanating from the sea is felt more strongly than the others suggested , which is not surprising given that students live in close proximity to the Adriatic Sea. Finally, an overview of the distribution of the level of engagement in the FFF protests in the 9 terminal nodes might help to better understand the paths just drawn . The paths leading to these distributions are shown in detail in the last column of Table 3. The methodology of decision trees for ordinal variables provides terminal nodes that have the most powerful interrelations with the selected predictors. The paths to the terminal node are determined by the splitting criterion based on the impurity reduction approach of the CART algorithm. It allows us to look at the variable importance measures that led to the final solution. Figure 4 shows the normalised importance plot for all predictor variables used in the tree. It confirms that extreme weather events, specifically storm surges, tornadoes, extreme temperatures, droughts and floods, have the same importance as the positive outcomes that can be achieved by people protesting to focus policy makers' attention on sustainability. It is clear that these predictors are more effective than the others which are at the bottom of the list and have decreasing importance, probably because they are mandatory behaviours and because they are seen as incapable of stopping environmental degradation at this time. It is known that variable selection bias can occur with CART method, resulting in predictors with many cut-off points being selected without taking into account the information they provide . To check for the presence of bias in our analysis, the RF technique was used . This technique was used to examine the importance of predictors in determining the levers that led the student respondents to protest and make their demands for a greener future in the interest of a global community. A forest of 5,000 trees was created to provide a robust ranking of predictors by importance. As can be seen in Fig. 5, the most important variable reducing overall uncertainty coincides with the first split, which relates to perceived levels of vulnerability to extreme temperatures due to climate change. Moreover, the most important predictors are the same as those shown in Fig. 4 in relation to the tree, albeit in different positions in the rank and this result confirms that the tree is robust. Overall, it is interesting to confirm that, among the ten main predictors in both analyses, six of them, namely STOSU, TORN, TMPEXT, DREXP, FLOEXP and FIREXP relate to the perception of vulnerability to natural disasters, the frequency of which has increased in recent years due to climate change. The results that the FFF movement has achieved in raising awareness among public opinion, and especially among policymakers, about the dangerous consequences of the increasing destruction of the planet, as well as the belief in the Fig. 5 Predictors ordered according to their importance in RF effectiveness of FFF in combating climate change, play an important role in young people's protests for a better future. --- Final remarks Straining natural resources and the entire environmental system are increasing anthropogenic pressures on the Earth and are expected to have catastrophic consequences for humans if they are not stopped. Among the various approaches proposed by researchers to address the problem and find the best solution, Bengquist et al. focused on individuals changing their behaviour towards environmentally friendly behaviour to achieve a more sustainable future. A pro-environmental behaviour can be defined as one which "harms the environment as little as possible or even benefits the environment" . Relatedly, a growing body of literature provides evidence that current mitigation efforts and future emissions commitments are unable to meet the temperature targets set out in the Paris Agreement ; therefore, new ways of reducing emissions must be adopted. We share the theory of these scientists and hypothesise that, in theory, all measures taken by governments to protect the environment can benefit our planet in the long run, but many recent climate disasters have shown us that we have little time and we have to stop climate change by taking vivid actions. There is an urgent need for citizens and businesses to incorporate environmentally friendly practices into their lifestyles for the sake of a sustainable future. Many people are aware of the seriousness of the environmental problem, but some probably still believe that it is happening in such a remote place that the negative consequences are not perceived as urgent . Since 2018, a global movement of students called FFF has drawn the attention of politicians and public opinion to the seriousness of the environmental situation, turning their fear of an uncertain future into a call for activism . FFF was able to mobilise many students who had experienced activism for the first time and felt the need to put pressure on politicians to listen to science . The effectiveness of the FFF is more likely due to the fact that it is a global mobilisation wave composed of young people who are best informed about disasters and ecological risks through social media and traditional media, which contribute to increased concern. Many scholars believe that studies of young people's engagement with climate change are "a matter for closer investigation" about climate activism and provide a better understanding of the younger generation . This study aims to contribute in this direction by examining students' perceptions of environmental issues and subsequent actions. We assume that young people who are so concerned about their future should take action, either by participating in school strikes or by acting ecologically 1 3 Perceived climate change risk and global green activism among… in their everyday lives, to reduce or even stop the causes of climate change. To this end, approximately 1,100 high school students in a large city in Southern Italy were surveyed. CART trees for ordinal data were used to analyse the relationship between participation in the FFF movement and the willingness to adopt ecological practices as a lifestyle. Specifically, we used the CART method modified by introducing a new impurity measure for a distribution-free tree-based supervised classification method for ordinal response variables . The proposed methodology is based on the assumption that the impurity measure must account for either the diversity or the order of the categories of the response variables. The novelty of the ordinal tree methodology proposed in this paper is its greater ability to distinguish groups based on the semantic value of the response categories. The classification system rewards individuals who give answers with the same semantics and distinguishes individuals with semantically opposite answers by using the central neutral answer as a cut-off. The results obtained in previous research confirm the suitability of the proposed approach . In this study, both the response variable and the predictors are ordinal, and their categories exhibit diversity that must be handled correctly because they correspond to ranks that have the same absolute distance from each other but opposite semantic meaning on the left and right sides of the cut-off. Through the responses collected, we were able to understand the levers that lead young people to act within the framework of climate activism. It has been shown that the levers that drive students to protest and make their demands for a greener future in the interest of a global community are initially based on their concern about the negative impacts of climate change and the awareness that the worsening situation will spiral out of control if we do not take immediate action. The responders are well informed about what is happening to the planet and view the environment as a whole system whose events can negatively affect their future. This awareness feeds into their environmentally friendly behaviours and lifestyles as they adopt key ecological practices, namely recycling plastic, glass, paper, and organic waste; using organic products and biodegradable materials; reducing waste and reducing plastic consumption. The students interviewed believed that global green movements such as FFF and climate activism in general could help effectively combat climate change by alerting policy makers to the urgency of environmental degradation. --- Appendix --- See Table 4 --- Consent to publication This manuscript has not been published anywhere and is not being considered for publication elsewhere. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. --- Authors and Affiliations Angela Maria D'Uggento 1 • Alfonso Piscitelli 2 • Nunziata Ribecco 3 • Germana Scepi 4 Alfonso Piscitelli [email protected] Nunziata Ribecco [email protected] Germana Scepi [email protected]

In recent years, the increasing number of natural disasters has raised concerns about the sustainability of our planet's future. As young people comprise the generation that will suffer from the negative effects of climate change, they have become involved in a new climate activism that is also gaining interest in the public debate thanks to the Fridays for Future (FFF) movement. This paper analyses the results of a survey of 1,138 young people in a southern Italian region to explore their perceptions of the extent of environmental problems and their participation in protests of green movements such as the FFF. The statistical analyses perform an ordinal classification tree using an original impurity measure considering both the ordinal nature of the response variable and the heterogeneity of its ordered categories. The results show that respondents are concerned about the threat of climate change and participate in the FFF to claim their right to a healthier planet and encourage people to adopt environmentally friendly practices in their lifestyles. Young people feel they are global citizens, connected through the Internet and social media, and show greater sensitivity to the planet's environmental problems, so they are willing to take effective action to demand sustainable policies from decision-makers. When planning public policies that will affect future generations, it is important for policymakers to know the demands and opinions of key stakeholders, especially young people, in order to plan the most appropriate measures, such as climate change mitigation.

Introduction Oesophageal cancer remains an important public health concern globally owing to its aggressive nature with an overall 5-year relative survival rate around 20% [1]. Worldwide, oesophageal cancer is the sixth most common malignancy accounting for over 500,000 cancer deaths each year [2,3]. Oesophageal squamous-cell carcinoma and oesophageal adenocarcinoma are the two main histologic types of oesophageal cancer. OSCC is the predominant histological type of oesophageal cancer worldwide and is more common in Asia, whereas OA is main histologic type in high income western countries [4][5][6]. The known risk factors for oesophageal cancer are tobacco smoking, excessive alcohol consumption, low fruit and vegetable intake, high intake of red meat, the consumption of very hot beverages, genetic factors, gastro-oesophageal reflux, and obesity [7,8]. Over the past few decades, linear declines in oesophageal cancer incidence have been recorded worldwide [9][10][11], whereas, in some regions, its incidence has been stable [2,9]. However, the recent global trends have not been assessed in many regions including the middle eastern countries specifically in Kuwait. Therefore, this cross-sectional cohort study assessed the secular trends in population-level oesophageal cancer risk by age, sex, and nativity in Kuwait. --- Methods In this cross-sectional cohort study, oesophageal cancer incidence data were obtained either from the Kuwait Cancer Control Center Registry or projected . For each oesophageal cancer patient, we obtained the date of birth, age at diagnosis, sex and nativity . Relevant Kuwaiti population data were obtained from Public Authority for Civil Information, Ministry of Interior, Kuwait. Mid-year population counts for each year and by subcohorts were defined as the person-years. Age-standardized incidence rates of oesophageal cancer overall, by year for unstratified data and by the subcohorts defined by cross-classification of period of diagnosis , age at diagnosis , sex and nativity were computed using World Standard Population as a reference across age, sex, nativity and periods were evaluated. Outcome variable i.e., count of incident oesophageal cancer cases was overdispersed with excessive structural zeros, therefore, it was analyzed using zero-inflated negative binomial model. Univariable and multivariable ZINB models were fitted to the data and ZINB models' coefficients and their corresponding standard errors were used to compute both unadjusted and adjusted incidence rate ratios and their 95% confidence intervals respectively, which were used for the models' interpretation. --- Results During the study period, a total of 496 cases of oesophageal cancer in 12.8 million person-years at risk were diagnosed. Of these, 269 were OSCC, 147 AC and 80 cases were histopathological unspecified. Subsequently, all the histopathological types were grouped as oesophageal cancer cases. The overall ASIR of oesophageal cancer during the study period was 10.51 . The ASIRs by age, sex, nativity and time periods are shown in Fig. 1. The highest ASIR of oesophageal cancer was among 70 years old or older individuals . The ASIR of oesophageal cancer was higher among males than females . The highest ASIR of oesophageal cancer was observed during 5-year period of 1980-84 followed by a consistently declining trend in subsequent 5-year periods. This declining trend was consistent across males and females as well . The multivariable ZINB model revealed that compared with the individuals younger than 30 years, the oesophageal cancer risk significantly increased through the higher age groups . The oesophageal cancer risk among males compared with females was only marginally significant . Furthermore, compared with the non-Kuwaiti residents, the Kuwaiti nationals were significantly at higher risk of developing oesophageal cancer during the study period . Moreover, compared with 1980-84 period, in each of the subsequent 5-year periods, adjusted IRRs showed a significant and nearly a consistent declining tendency . --- Discussion The results showed that during the past four decades, the overall ASIR of oesophageal cancer was 10.51 in Kuwait. This estimate is comparable with those recently reported in Eastern Asia , but is nearly twice as much of the estimates reported from South-Central Asia , sub-Saharan Africa and other world regions [13]. This global variation in ASIRs of oesophageal cancer may be owing to varying lifestyle and dietary patterns. The two established risk factors for oesophageal cancer are excessive alcohol consumption and tobacco smoking. Parenthetically Kuwait ranks very high worldwide for tobacco consumption prevalence in men and women [14], with parallel high ASIRs of oesophageal cancer, which indeed fulfils the Bradford Hill's criterion of 'coherence' for causal link between tobacco smoking and oesophageal cancer. The multivariable ZINB model showed that increasing age was associated with the increasing trend in the oesophageal cancer risk, which reflects a cumulative effect of carcinogenic exposures. The modification of known risk factors for oesophageal cancer may lessen the risk later in the life. Moreover, males had marginally increased oesophageal cancer risk than females, which outwardly related to sex hormones and lifestyle factors including smoking and dietary factors [7,8]. Additionally, over the past four decades, oesophageal cancer risk consistently declined in Kuwait. Towards the end of twentieth century oesophageal cancer risk had been increasing in both sexes in USA, Europe, Japan and China [15,16], which in recent decades showed a declining trend in these regions as well [15]. Similarly, downward trends with varying magnitudes in oesophageal cancer incidence were recorded in Hong Kong [17], and China [18]. These declining trends in oesophageal cancer incidence ostensibly is due to varying distributions of contributory risk factors across different populations [15,19]. For example, in Kuwait, tobacco smoking by any mode including cigarettes, cigars and pipes showed a consistently declining trend with varying rates from 2000 to 2018 and stabilized thereafter, which seems to concur with the decreasing trend of oesophageal cancer in Kuwait [20]. In conclusion, an overall high oesophageal carcinoma ASIR was recorded. ASIRs consistently declined from1980 to 2019. Older adults and Kuwaiti nationals were high-risk groups for oesophageal cancer. An educational intervention based on the known risk factors may alleviate oesophageal carcinoma risk in this and similar settings. Future studies may contemplate to evaluate the effect of such an intervention. --- Data availability The dataset used in this study can be made available on a reasonable request to the corresponding author and additional approval of the Director, Kuwait Cancer Control Center Registry. --- --- --- --- Competing of interests None declared. --- Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background This cross-sectional cohort study assessed the inequalities in oesophageal carcinoma risk by age, sex and nativity in Kuwait: 1980-2019. Methods Using oesophageal cancer incidence data from the Kuwait National Cancer Registry, relevant Kuwaiti population data and World Standard Population as a reference, age-standardized incidence rates (ASIR) (per 100,000 person-years) overall and by subcohorts were computed. The incident oesophageal cancer cases count was overdispersed with excessive structural zeros, therefore, it was analyzed using multivariable zero-inflated negative binomial (ZINB) model.Overall ASIR of oesophageal cancer was 10.51 (95% CI: 6.62-14.41). The multivariable ZINB model showed that compared with the younger age category (< 30 years), the individuals in higher age groups showed a significant (p < 0.001) increasing tendency to develop the oesophageal cancer. Furthermore, compared with the non-Kuwaiti residents, the Kuwaiti nationals were significantly (p < 0.001) more likely to develop oesophageal cancer during the study period. Moreover, compared with 1980-84 period, ASIRs steadily and significantly (p < 0.005) declined in subsequent periods till 2015-19. Conclusions A high incidence of oesophageal cancer was recorded in Kuwait, which consistently declined from 1980 to 2019. Older adults (aged ≥ 60 years) and, Kuwaiti nationals were at high risk of oesophageal cancer. Focused educational intervention may minimize oesophageal cancer incidence in high-risk groups in this and other similar settings. Future studies may contemplate to evaluate such an intervention.

With a similar alignment in values, open scholarship has the potential to be considered part of 'decolonisation' efforts . Decolonising the curriculum represents a broad notion , typically referring to a focus on addressing the continued existence of embedded oppression and western privilege and attempts to achieve better recognition and development of alternative knowledge . In practice, decolonisation demands transformative change to challenge the disproportionate power represented and perpetuated through the systems and knowledge presented. For example, not to look at how western theories apply to the global south or to see work from the global south as an 'alternative perspective', but rather to consider and voice knowledge created within different areas as contributing to cumulative developments in our shared understanding . This work goes beyond developing a diverse curriculum or inclusive assignment to acting on the inequalities, oppression and discrimination perpetuated by current structures, cultures and practices towards greater social justice . These movements of open scholarship and decolonisation are clearly not the same. However, there are several shared values inand shared barriers topromoting progression and it is hoped that this work, in elucidating these similarities, will promote further collaboration and synergy between such communities. --- Shared values The open scholarship movement is perceived to rely upon the Mertonian norms which describe the ideal scientific ethos and include the principles of communism and universalism . These values are often considered to be implicit in the practices adopted and are often inconsistently achieved . For example, the financial barriers to publishing with open access means the geographical diversity of represented authors tends to be less than that of non-open access publications . Decolonisation is to decentre colonial-driven knowledge, perspectives and practices, instead transforming organisations and knowledge to represent a wide range of inclusive structures, positions and voices. Such work is often framed within certain groups of institutional values, such as 'Equality, Diversity, and Inclusion' or anti-racism , although the specific values and practices represented are commonly contested . Both decolonisation and open scholarship share an obvious moral motivation, but there is little consensus in the central values held. Despite this, they demonstrate shared priorities and goals in trying to promote long-term changes which challenge the problematic status quo and promote a more representative and accessible research and knowledge infrastructure. In this manner, developments in each domain are co-dependent. For example, we can better challenge the overrepresentation of white, male, Eurocentric knowledge when there are fewer barriers for anyone to access, engage with, create and disseminate knowledge. Similarly, we can foster more meaningful collaboration and inclusive environments and thereby create more alternative knowledge, when we transparently recognise and reward different types of contributions to research and knowledge generation . --- Shared barriers Decolonisation initiatives and open scholarship communities share a number of common barriers when attempting to drive change. For example, within both initiatives, there are plenty of misunderstandings relating to the multifaceted nature and changing scope of action necessary to drive meaningful change. Many universities are currently implementing decolonisation initiatives which do little more than check that the reading list is not entirely white . Changes to course content and assessmentor indeed to the wider structures and policies of the universityare minimal . Other similar assumptions are made within open scholarship practices: for example, that sharing datafiles without associated codebooks, data dictionaries or metadata is sufficient for transparency . This being the case, concern continues in relation to both developments about 'open-washing' or tokenistic decolonisation work where there is an attempt to 'tick the box' without clear quality control . The institutional softening of more radical changes into narrow individual-level metrics in both decolonisation and open scholarship is common and highlights the shared need for higher standards of implementation and greater structural-level thinking. To make incremental progress in either domain, holistic and sustained change is required. Initiatives which do not consider all stakeholders and which disregard the problems with the wider systems and processes are unlikely to succeed. The status quo tends to be well-defended by those who have historically secured privilege from it and, in consequence, there are often substantial amounts of both structural and individual resistance to any attempt to drive such dramatic change. Some communities and stakeholders are currently making developmental progress and slowly improving standards across institutions and geographical boundaries. Most universities in the United Kingdom have decolonisation groups and there are international open scholarship groups, such as the Framework for Open and Reproducible Research Training for open scholarship pedagogy. Such communities are commonly led by early career researchers and/or those who are most excluded by existing practices . Development in these areas is therefore heavily restricted by: the lack of recognition ; the physical, emotional and psychological burdens often experienced in attempting to overcome resistance; and the wider structural issues in higher education, like precarious work contracts . Groups attempting to tackle decolonisation and open scholarship simultaneously are only just forming; for example, the Advancing Big Team Reproducible Science through Increased Representation Team . These are integral communities which require sustained support, funding and infrastructure. --- Concluding Thoughts Both open scholarship and university decolonisation practices are of vital importance and require continued investment and championing by many stakeholders. Greater synergy between the communities leading such efforts could maximise positive impact. Open scholarship is about making things open, but it is crucial to consider what should be open and for whom . There is potential for open practices to perpetuate or extend existing inequalities, rather than promote collaborative knowledge development and so the adoption of a decolonisation perspective could maximise the accessibility of work through more thorough consideration of power, geographical differences and diversity in knowledge sources. Similarly, greater sharing and transparency of decolonisation effortswhether through diversification of viewpoints, dissemination of evidence about specific practices, or the implementation of open materialswould facilitate more rapid developments in understanding and action whilst also exposing superficial practices. Thus, through greater collaboration between the open scholarship and decolonisation communities, we have the potential to drive further societal progress and justice.

Open scholarship and university decolonisation communities share several values in attempting to promote long-term changes which challenge the problematic status-quo and promote a more representative and accessible research and knowledge infrastructure. Initiatives from these groups often experience similar barriers when attempting to drive such change. The current work therefore argues that further societal progress and justice could be possible with greater collaboration between open scholarship and university decolonisation communities. Open scholarship is a movement to make "knowledge of all kinds more accessible, transparent, rigorous, reproducible, replicable, accumulative and inclusive" (Parsons et al., 2022). Whilst broad, this definition includes a wide range of individual practices and structural changes, including open educational resources, citizen science, open-source software, open peer review and open data, among many others. Such efforts can help tackle many inequalities by challenging, changing or removing exclusionary practices which have been perpetuated by ideological hegemony. For example, pre-printing research on open platforms like the Open Science Framework (osf.io) gives researchers the opportunity to disseminate knowledge and be acknowledged for their contributions, making their work more widely accessible, without the need for either researcher or reader to overcome privileged gatekeeping, approval or financial barriers. Facilitating accessibility and inclusivity are key parts of most models and visions of open scholarship (Syed and Kathawalla, 2022; UNESCO, 2021). For example, open scholarship is considered highly compatible with feminist perspectives (Siegel et al., 2021;Matsick et al., 2021), where exclusion of women, inequalities in invisible labour and recognition, and marginalisation of knowledge created by women, can be challenged. Open scholarship practices are considered predominantly (but not exclusively) positive in helping overcome the precarity faced by minoritised researchers when negotiating power, championing their voice, and democratising knowledge generation and dissemination (Fox et al., 2021;Pownall et al., 2021).

Introduction Sexual violence victimization is unacceptably common in the United States , with 18.3% of women and 1.4% of men reporting lifetime experience of sexual assault, defined as attempted or completed forced penetration or alcohol/drug-facilitated completed penetration; 1.1% of women experienced this in the past year [1]. Almost half of women and one in five men report lifetime sexual coercion and/or unwanted sexual contact [1]. The physical and mental health effects of sexual violence victimization include physical injury, depression, anxiety, post-traumatic stress disorder , attempted/completed suicide, substance abuse, and sexually transmitted infections [1]. Sexual violence has been estimated to cost individual survivors nearly 125 thousand dollars; the population economic burden is estimated to be over three trillion dollars, driven in part by physical and mental health treatment costs, lost work productivity, and property loss and damage [2]. For young people in college, sexual violence experiences have serious academic consequences [3]. The recent wave of disclosures of sexual violence, including Emma Sulkowicz's BCarry That Weight^endurance performance art, Tarana Burke's #metoo movement and Time's Up, has renewed public discourse around chronic sexual assault, harassment, and coercion of women and sexual minorities as an Bopen secret^in many fields and spaces. College campuses are one such space [4]. Among women who report lifetime sexual violence victimization, 37% first experienced it between 18 and 25, often while attending college [1]. According to 2015 US Department of Education's Office for Civil Rights data, sexual violence complaints on campus increased more than 1000% between 2009 and 2014 [5,6] reflecting an increased willingness to report sexual violence, due perhaps to more university-based reporting mechanisms as well as survivors' unwillingness to maintain the secrecy upon which sexual violence perpetrators depend. In response, national-and state-level policies to prevent and respond to sexual violence emerged, with some requiring prevention training for students, faculty, and staff. Although the evidence based on prevention programs for college students is limited, key mediators and interventions include sociorelational skills, consent, bystander behavior, and empowerment [7]. Just three campus-based prevention programs for men have been rigorously evaluated [8][9][10] and some bystander-focused programs and a social marketing campaign have shifted bystander intervention attitudes, intentions, and behavior [11][12][13][14]. Rape resistance/self-defense has shown efficacy for women [15,16] but has not been tested among men. Although design and evaluation of sexual violence prevention programming has increased, the majority of evidence-based prevention programs were designed for and evaluated in residential and non-urban college settings, where the majority of students reside on campus and are white. Of all but one of the programs described above, the percentage of non-white students in the samples ranged from 10 to 32%. RealConsent was tested on a sample of less than 50% white students, with a third being Black/African-American or Latino/a/x students and though the setting was urban, it was not a predominately commuter campus. Many evaluations of sexual violence prevention programming do not report the proportion of sexual orientation and/or gender identity minority students, although some do [17]. As we develop our understanding of urban commuter campus student experiences of sexual violence [18], there is an urgent need to focus on sexual orientation and gender identity minority students in general [18]. A major gap in the prevention research base is that there are no sexual violence prevention programs designed specifically for urban, commutercampus students, who are more likely to be simultaneously racial/ethnic minorities, immigrants, LGBTQ+, and/or gender non-conforming. In addition to occupying multiple, often marginalized, identities, urban, commuter campus students have qualitatively different experiences of Bstudent life^and often feel less connected to their campus [19]. Greek life has less prominence on commuter campuses, and organized athletics may also have different influences on students' social lives [20]. Socializing is more likely to happen at bars and clubs or at off-campus parties and student engagement is different and may be weaker [20,21]. Some empirical research exists suggesting that the urban commuter campus setting merits focused study. When Bringing in the Bystander [11] was tested among male students at an urban university with a high percentage of commuter students, efficacy was diminished perhaps due to decreased feelings of connectedness to the campus and student community [22]. Urban commuter students may require tailored approaches [22], with focused research exploring sexual violence and sexual violence prevention among urban commuter campus students. The Commuter Campus Student Perspectives on Sexual Violence Study is a qualitative in-depth interview study designed to begin to fill the gap in the literature and explore how urban commuter campus students conceptualize sexual violence and imagine prevention programming working in their lives. --- Methods --- Procedures The study was conducted in spring 2017 at a public, predominately commuter, 4-year college in a major urban university system in the US. Both print and on-line media outlets were used to recruit eligible participants. Flyers were placed where students congregate at the focal college and on other college campuses in the same urban university system. Participants who saw the flyer or clicked on the on-line ad were redirected to the anonymous on-line survey, where the study was described; interested participants engaged in a web-based consent process, before completing the survey. Eligible participants had to: [1] attend/have attended one of the urban college or university system's colleges in the past 24 months; [2] be between 18 and 24 years of age; [3] reside in the focal metropolitan area; [4] report a recent sexual experience that meets criteria for sexual coercion, harassment, or violence; and [5] communicate in English. Sexual coercion, harassment, or violence was defined by responding yes or maybe to the following questions: Bhave you ever had sexual contact that you consider to be unwanted or without your consent in any way?^and/or Bhas anyone ever tried or made you have sex with them, when they knew you did not want to?^. If eligible, potential participants then completed the on-line contact card, collecting minimal contact information , so that an appointment could be scheduled. Of the 463 individuals who responded, 20% were eligible and left contact information; of these, 19% made an appointment and engaged in an in-depth interview. Upon arrival at the research site, participants completed the written informed consent process and then engaged in the interview with a trained female interviewer in a private room. All interviews were digitally audiotaped and transcribed professionally. Victim support and mental health resources were offered to all participants and support in accessing them was provided as needed. City University of New York Institutional Review Board reviewed and approved the study. Using these methods, we conducted 18 in-depth interviews. --- Interview Content The in-depth interview guide focused on several areas, and was organized into three areas: social identity and life; sexual experiences and definitions of sexual violence; and response to sexual violence. In the first area, we explored participants day-to-day life and experiences as a student and the impact of their identities on various life domains . In the second area, we focused on: sexual experiences ; how participants defined the spectrum of sexual experiences ; how they knew when someone is Bcrossing the line^; factors that influence how students conceptualize sexual violence; the role of alcohol and substance in sexual violence. Finally, we explored student experiences with and thoughts on support services access, sexual violence prevention, and experience with prevention programs. --- Analysis Thematic analyses were conducted to identify and describe the main themes that emerged from the data and analyze patterns in the data. First, after each interview, to contextualize the data, a transcript summary and a qualitative memo, describing the interview context and immediate impressions, were developed by the interviewer or project coordinator . All transcripts were read by the first and last authors. Next, in order to categorize the data, coding was conducted by the first author using QSR International's NVivo 9 qualitative software , guided by conceptual maps that reflected the interview and focus group guide question domains. As new domains or areas emerged, new codes were added; if an existing code needed subcodes to reflect better the nuance of the text, subcodes were created. Next, queries were run to group same-code text from different transcripts; these were read by the analytic team to identify the themes. The analytic team met regularly to discuss the data and aggregate codes into major themes. The team re-read all of the transcripts to ensure that the coding and themes identified were congruent with the data and refinements were made as needed. Next, a matrix was created reflecting the major themes and key insights identified with coded text to support each area across all interviews. --- Results --- In-depth Interview Sample We screened 426 individuals via an anonymous webbased survey; of these, 113 reported experiencing sexual violence in their lifetimes and were eligible for interview. Of these individuals, half reported that they had also experienced it in the past year and were eligible for interview. Of this group, 18 participated in the in-depth interviews. Twelve participants self-identified as straight females, one self-identified as queer female, and one identified as straight male. One identified as bisexual female, two as gay male, and one as bisexual male. The average age was 21, with the youngest participant being 18 and the oldest 22. Five participants self-identified as White or Caucasian and another five as Latino or Hispanic; four identified as Black or African-American and two as Asian. One identified as bi-racial and one did not identify in terms of race or ethnicity. All participants were current college students, 8 of them also had a job. Sixteen lived in the metro area; two lived just outside the city. Interview participants did not differ significantly in terms of age, race/ethnicity, or sex/gender, as compared with individual who screened eligible for the study. --- Thematic Analysis Results Here, we present thematic results in three broad areas. The first are the general experiences and perspectives as commuter students that may be relevant to the development of sexual violence prevention programming, including Bcommuter student life^and Bsocial identity^. The second is how commuter students defined and identified sexual violence. The third area is their thoughts on and experiences with support services and prevention programming. To enhance confidentiality and because of the small number of interviews, no descriptors and only numeric codes are used to label participant quotes. --- Commuter Student Life --- Overlapping Roles The majority of the students interviewed stated that Bevery day is on campus^ and that they spent Ba lot^ of time there. The students' day-to-day schedules were reported to be Bpretty hectic^, with some stating that they spend the rest of their time either at work or attending groups or clubs. Thus, Bit's always either school or work^ and sleep Bwhen they get the chance^. About half the sample reported holding a job and another half reported being involved in student groups/clubs either on-or off-campus. Just one participant reported being part of an oncampus fraternity. Most of the students in the sample lived off-campus but it was clear that there were two different experiences reflecting the distinct social contexts each set of students inhabited. Five out of 18 interviewees lived in the college dorms and two split time between the dorms and their family homes; the remainder commuted. Both commuter and dorm students highlighted the significant difference in the student experience between living in the dorms and commuting to school, as well as the difference between the groups of students who live in the dorms and those who commute. Participants who lived in the dorms described it as Bfun^, saying it was Ba good experience^that helped them Bmeet a lot of new people, and make friends^. Several students noted that Bpeople who live in the dorms are kind of in a closed circle^; another saying that everyone had their own Bcircles^. Three of the five students who lived in the dorms reported that they usually socialized with other people from the dorms. Some students who lived in the dorms noted the difficulty of socializing with commuter students; one noted Bright after class they leave because it takes them two and half hours to get home^. Another student noted that commuter students had very busy schedules and no time to socialize; commuter students Bare always running from different places and like different schedules^. Commuter students also reported difficulty making friends; one participant said Bsince it's a commuter school, it's hard to make friends … because people just come here and they just leave because they're just here for school and that's it^. Difficulties in socializing with their peers and on campus emerged for commuters because of both the distance and time that commuting demanded, as well as the insularity of students who either lived in or had a Bhome base^in one of the campus dorms. When commuter students socialized, students reported socializing in a range of spaces. About half reported that they usually Bhang out^in the neighborhood; two reported socializing in the dorms and the remainder in various places such as downtown and/or midtown and other popular areas of the city. Just two commuter students reported that they have friends from classes past and present. Some commuter students reported not having time to Bhang out;^one reported BI just do all my work here and then I go home once I'm done^. Commuter students traveled into the campus neighborhood from a wide area, with one student noting that commuters tended to be Breally scattered^. Students commuted from within the campus' subarea, as well the other subareas of the city, and two key suburbs. Commutes to some of these areas represent an hour plus each way. --- Social Identity The role of students' social identities, both sexual and gender and race/ethnic identities, emerged strongly as salient to both students who commute and who lived in dorms; social identity acted as a lens through which they filtered their experiences in general, on campus and, at times, of violence. Two-thirds of participants identified skin color or race/ethnicity, specifically identifying as Black, Latino/a/x, or white, as important to them. Three participants self-identified as being Ba product of immigrants,^highlighting the relevance of immigrant status to self-identity at a university system in a city that is 40% foreign-born or born outside of the US. Some students also emphasized how important gender is to their identity and experiences; Bgender is a huge part of my identity^said one female student . Further, some participants noted that they are experiencing a stronger awareness of their race/ethnicity and/or sex/ gender in the current US socio-political climate, noting that race and ethnicity is important Bespecially right now^, Bin today's day and age^; one female participant said that she is having Bconversations that I never had before about femaleness that I do have now^. Many of the female respondents, particularly those who self-identified as children of immigrant parents, noted that they had been raised in Btraditionalô r Bpatriarchal^ways by their parents who encouraged them to be Bgirly girls.^One student noted that Bpeople's view of me as a white person, as well as being a white male, is interesting^. Several identified how intersections among their race/ethnicity and gender influenced their lives and how they are treated on campus; for example, one respondent noted: Some students underlined the importance of agreeing and consenting prior to the sexual encounter, by saying that crossing the line is when the sex partner does something that you have not consented to, and that if a sexual act-that wasn't agreed upon-was enacted, the line has been crossed and a violation has occurred. Just one participant described the dynamism of sexual interactions and the role of giving consent or not to each step or aspect of it, in order to make it fully consensual and enjoyable for both parties. They said BI mean, you can first consent to something, butwhich might excite the other person and basically get more into it and get more intense, I would say, which would later -like a consenting experience would become a forceful experience just because you've basically leveled up, like that person kind of made it more intense.^. This student went on to say that a good sexual experience could Bturn bad if a person's behavior … is not expected from the other person, and is not experienced well from the other person^. This was the only student who described the role of consent in the escalation of sexual activity, suggesting a diverse sexual repertoire that could benefit from specific consent agreements. Other participants suggested that consent could be Bimplied;^for example, when a guy Btakes a girl out^, Bpays for the dinner and the gas^, and then invites the girl to his house. In such situations, the guy would Btry to initiate something^ and would then expect Bsomething in return.^Some students said then that they would Bfeel like you have to^ because you are already in that kind of setting , as if by doing all the previous steps, especially Bgoing to his house^, consent to the sexual encounter was given. When asked how they knew that a sexual experience is Bgood/bad, wanted/unwanted, forced/not forced, coerced/not coerced^some participants, focusing on what was Bgood^or Bnot good,^identified Btrust^as an important factor in order to label a sexual experience as a good one. For some, trust was intertwined with feeling good, either Bphysically and emotionally^; for others, it was connected to the ability to be Bopen^and Bvoice things out^with the sexual partner . One student said Bwhen it's 'wanted' and when it's what you consider 'good' and you're happy about it, there's not that kind of small thing in your head saying, 'something is not right. I don't know if I want this'.^. Some students described Bunwanted^sexual experiences as ones when Bsomething happens and you don't want to, but you let it happen anyway^because you Bdon't know how to say no^. Another described it as something that Byou do just to make the other person happy^. For some, it seems that even if Byou don't want to do what you're doing^they would not say no because they want to Bget together^with the person or have a relationship with them . Other experiences that qualified as Bunwanted^included ones where the students did not feel comfortable saying no, for example in the past when they were younger, so they tried to just go through it without expressing their feelings . A clear definition of an Bunwanted^sexual experience involved being intoxicated and/or not being aware of what is happening, Support Services Access and Reporting Just less than half of participants never accessed any sort of support service in their lifetimes . One participant reported accessing only Bhealth checks^, while another two mentioned having a very good support system . Regarding their sexual violence experiences, one student stated that they tried to Bdeal with it^by themselves ; another reported having never thought about reaching out for support services. Half, though, reported having accessed support services for general reasons; most reported that Bit was really helpful^, helping them Blearn about themselves^. One proponent of support services noted: Bgetting support is always the best thing to do, and nobody should ever face anything that they feel bad about on their own^. However, one participant described the stigma that still surrounds accessing support services; in fact, in some cultures Bit means you're weak or like the mentally ill^. Of the participants who described their experiences of sexual violence and/or coercion during the interview and reported accessing services, two did not disclose the violence experience to the therapist. One reported that they Bsort of pushed that particular experience to the side^; the other reported that they did not realize how Bbad it was^. Another participant stated that it took a while to open up and disclose their experience with the therapist, and that they were not really listened to until they said that they were sexually assaulted . When asked about how and where to access sexual violence support services, should they be needed as a student, fully half of the participants stated that they would not know where to go or what to do, either onor off-campus. Of those who had ideas about where to go, they mentioned a range of options, including reaching out first to public safety; another two said that they would research it on-line first; two identified the on-campus counseling center; another mentioned oncampus self-defense classes; finally, one student stated Planned Parenthood. Two emphasized the importance for a service to be anonymous and to protect people's identities. One student stated that the on-campus support services have Breally inconvenient hours^. When asked if they would report a sexually violent experience, no students immediately indicated they would report without qualification. One stated that they encouraged a friend who has been sexually assaulted to file a police report, and that they would definitely encourage somebody else to reach out to Bsupport services^for such a traumatic experience. In considering reporting, two participants pointed out the difference between being assaulted from an acquaintance or a stranger: Bif I was walking down the street and like a guy just raped -or a guy like, you know, forced himself on, raped me or whatever, I would definitely go. But like, you know, I wouldn'tand it sounds so messed up, but if it was likenot a friend, but if I was someone that I knew. Like, I didn't report him^. Another student said Bif it's some random person I guess, yeah, I'd report it. But then, if you were in a relationship, somebody wouldn't really want to report that, just because they may love the person or whatever^. Another participant stated that they would not report it and would not even tell their parents, if the perpetrator was an acquaintance, because they would blame them for being in such situation. They said: Bif it was someone I knew, I honestly don't think I would tell my parents. But if it was someone I didn't know, I would tell my parents^. The student went on to say BI feel like they would say, well, why where you in that situation?T his would trigger Bthat feeling of like it's your fault kind of thing^. --- Commuter Students' Views on Prevention When asked if, in their opinion, it would be possible to prevent sexual violence, the majority of the participants responded no, with three saying that it is Bnot possiblet o prevent sexual violence or in the Bgrand scale of the world^. Others were more qualified noting that it is Bhard to say^, or that sexual violence could only be prevented Bto a certain extent^. When asked how it could be prevented, one participant stated that they would attend a self-defense class, because that it is the only way to prevent sexual violence, other than Bnot socializing, not doing anything, and staying in a bubble for the rest of my life^. Another said that a way to feel a Blittle safer^would be carrying pepper spray as a precaution. Three students emphasized the role of the individual, saying Byou can't control what people do all the time^, or it is Bbasically within each individual^ with risk varying from Bperson to person^. Just five participants described ways to reduce the risk of sexual violence victimization, including having conversations, having a good sense of self-awareness, educating children and adults, addressing societal stereotypes, changing social norms, understanding and discussing consent, teaching girls/women that they can say Bno^, not blaming the victim, and teaching people that there can be abuse within the queer/non-gender binary community. The majority of participants said that they would be interested in attending a prevention program, because it is Breally important^but had Bnever heard about or done anything like that^ and Bpeople still don't know how to prevent it^. Students said that they Bwould encourage people [other students] to go^ and would like to bring other students in order to Bshare the information^. One underlined the fact that prevention programming would be helpful especially for a commuter school because Bas much as the school might protect while they're in here, I think when people leave campus…t hey need the knowledge and skills that programming could provide. They went on to say that BI think there is a lot of like informing of -informing students what the options are, you know, when they're not on campus. When asked for advice in order to plan an effective prevention program, students brought up various suggestions. Almost all said that talking would be important and effective, identifying specific topics, such as Bwhat sex is^and Bwhat sexual violence can be.D iscussing consent was identified as critical and activities such as lectures and workshops were highlighted as possibilities. Two students noted the difficulty of talking about sex with adults; one stated that talking about sex is Bweird^especially if it is a teacher talking about such topic during classes, which it makes it Bhard for students to listen^; they noted Bwhen you feel equal to someone, it's easier to learn from them^, suggesting the desirability of near-peer educators. Another student said that there is still a taboo about having conversations about sex before initiating sex, because it is sometimes seen as unsexy , so prevention should address that as a barrier. Other prevention ideas included self-defense classes, showing video clips, and asking students to identify various situations as and label Bred flags^for sexual violence. The importance of holding Bplanned-out activities^was highlighted, as well as basic educational activities such as distributing information on resources and support. One person said that Bwe respond to things when they personally hit home^ so bringing survivors of sexual assault in the conversations, as well as their friends in order to share and support, would be an effective strategy. Another stated that the key is Bmaking it a topic that is not uncomfortable to discuss. Three participants underlined the importance of identifying and discussing the full spectrum of violence, from physical to sexual to emotional; two students said that they would split discussion groups into different genders . One student pointed out that young people today Bhave no attention span^so it is difficult to hold their attention; they suggested that a PowerPoint presentation would not be effective and that novel, youth-oriented media would be required. One person said that holding some prevention activity at venues such as bars or clubs would be an effective strategy; in contrast, another participant said that it would be Btricky^as bars often sponsor free entrance for girls so Bfor them it's business^. To recruit students to prevention activities, participants suggested sending emails through university accounts, sending Bsnail mailt o people's homes to reach students who are not on campus often, and distributing flyers. The importance of offering food and beverages was emphasized, but the limits on the time and availability of commuter students were also reiterated. --- Comment The commuter campus students we interviewed held similar perspectives as some non-urban students studied in prior research [23] regarding what constitutes sexual violence. These similarities are noteworthy and suggest that the foundations of existing sexual violence prevention strategies will be useful for urban commuter campus students. Specifically, the use of Bgut feelings^to identify when and how initially wanted and consensual sexual experiences can evolve into unwanted, coerced or violent ones is consistent with studies among young people both on and off university campuses [24]. The lack of clear and specific communication around consent is also consistent with the general literature on sexual violence among college-age young people [25]. This supports the current focus of existing sexual violence prevention programming on clearly describing what constitutes consent, how to communicate around consent, and skills for establishing consensual sexual relations. However, we also identified experiences of urban commuter campus students that may demand specific attention when designing sexual violence prevention programming, including the importance of multiple, sometimes overlapping, contexts, roles, and social identities. One unique aspect of urban commuter campus students' experiences is the lack of a single, consistent, and all-enveloping social context experienced with their campus peers and bounded by campus geography. Urban commuter students do not universally possess strong and focused connections to their school contexts and campus peers, via student clubs, Greek life, sports, living on campus, and time spent on campus. They also often have significant off-campus obligations that limit their ability to spend time on campus. Despite this, students noted that prevention skills taught on campus would be useful off campus, reflecting the importance of portable prevention skills. Further, while some students who live in dorms on campus may experience more campus-based social contexts that offer key sites for prevention work, many commuter students may need to be reached through strategies that travel with them, such as prevention that they can access while commuting or remotely may be critical to these students. For example, online training tools such as RealConsent and Take Care could be adapted as a mobile app that would permit commuter students to engage in the intervention while on a train or bus. Prevention strategies for urban commuter campus students must use examples and promote skills that reflect multiple salient contexts. For example, prevention might focus on educational activities or bystander intervention skills-building while on the commuter campus, but on workplace sexual harassment policies and protections while at work, reflecting the importance of work and school contexts for many students. Commuter campus students also enact different social roles simultaneously to a greater extent than residential campus students; thus, prevention strategies need to connect with these multiple roles, in addition to the various contexts within which they occur. This may require not only adaptation of current prevention programs but the development and offering of a menu of prevention options, based on context and role, for this group of students. For example, students who are parents may be provided skills for how to communicate with their own children on prevention; students who are siblings may also share prevention lessons with younger siblings. And, although this did not emerge as strongly as we expected, students' roles as children of adult parents living in the community may also need to be addressed. Testa and colleagues showed the effectiveness of providing resources to parents of incoming college students [26]. Adapting such an intervention for urban, commuter campus students will require significant work to fully understand the connection between urban commuter campus students, their parents, the community, and other salient contexts and roles. Finally, the intersection of various social identities is crucial to include in the design and adaptation of prevention programs for this group. Students were clear that prevention efforts needed to meet them where and as they are-to show them how it matters to their various roles and intersecting identities. Large urban areas often have population-specific violence prevention or social service provision non-profits and programming, such as those led by sexual and gender minority individuals. These organizations can receive communications from students, who may seek information via university services but may be more comfortable seeking services from such a group. Finding a way to connect students to this diversity of resources in a user-friendly, confidential, portable, and centralized way, could be an important goal for improving campus response. Such organizations can also be involved in the design and implementation of sexual violence prevention programming on campus. As experts in intersectionality and in working across varied community contexts, representatives from such organizations can inform the appropriate adaptation of current evidence-based and informed programming. An urban commuter campus can be a center for a multi-pronged, multilevel community engagement approach to preventing and responding to sexual violence both on and off campus and for students, staff, and faculty, as well as local community residents; such campuses can organize a tailored, community-based approach in partnership with community leaders, providing knowledge and skills for individual residents and higher-level interventions for groups, organizations, and spaces. This creates an opportunity for a much wider diffusion of prevention, yielding a ripple effect of prevention efforts that are carried beyond the campus and local community. This is both the challenge and the promise of prevention work in this unique context. --- Limitations Our results must be considered in light of several limitations. First, our sample is a purposive one but also one of convenience, recruited using web-based outreach and flyers. While overall, the sample is diverse in terms of ethnicity and age; the size of the sample for interviews is small, particularly given the size and diversity of the underlying population. As well, the study is set in a particular urban area and may not be generalizable to other urban areas. Second, quality assurance and consistency in data collection were achieved by employing a highly skilled interviewer, a comfortable interview environment, and modest incentives; however, some participants may not have been totally comfortable discussing sensitive topics such as sexual violence and help-seeking on campus or with the cisgender female interviewer. Because of these limitations, we reiterate that our results are suggestive and that further research is needed in this area. --- Conclusions Urban commuter campus students reported limited exposure to prevention programming and are in need of the knowledge and skills that evidence-based programming could provide. Reaching large populations of commuter campus students, who often move in and out of the student role and may even attend different campuses across an urban area, is a challenge. In addition, urban commuter campus students have distinct campus experiences, exist in multiple social contexts, and play varied social roles, all of which demand unique attention in the design and adaptation and evaluation of sexual violence prevention programming. Current programming has not been, to date, designed for them; future prevention programming needs to be tailored to address their unique contexts and lived experiences. Further research is needed to explore in more depth how their intersecting identities and community experiences influence their experience and recognition of sexual violence, as well as their help-seeing behavior. This will inform the design of prevention programming, which must be grounded in their lived experiences, designed in consultation with them, and in relation to campus and other communities important to and representative of urban commuter campus students. --- Data Availability Statement The data that support the findings of this study may be made available upon request from the corresponding author, VF. The data are not publicly available due to the nature of the data which contains information that could compromise the privacy of research participants. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Sexual violence victimization is unacceptably common in the US, with nearly half of women and one in five men reporting lifetime sexual coercion and/or unwanted sexual contact; much violence occurs in campus settings. The majority of sexual violence prevention programs designed to date were not developed around the needs of urban commuter campus students. The present study explored qualitatively how these students conceptualize sexual violence and prevention. Face-to-face in-depth interviews were conducted with students on how they recognized sexual violence and understood prevention. Interviews were audiotaped, transcribed, and analyzed. Commuter students used Bgut feelings^to identify sexual violence, reporting minimal direct consent communication. Intersecting social identities and multiple, concurrent roles limit the potential impact of existing prevention programs. Further research to design and evaluate tailored sexual violence prevention programming for urban commuter campus students is needed.

Introduction The ageing UK population is associated with a corresponding rise in the number of people requiring long-term care [1], with those entering long-term care having increasingly complex healthcare needs [2]. Currently, there is little evidence for much of the care provided in care homes [3,4], and concerns about the quality of care [5] have led to calls for a more structured and evidence-based approach to healthcare provision within care homes [6]. However, research involving frail, older people living in care homes is more complex and resource intensive than in other healthcare settings [7][8][9][10]. Given the wide range of questions that require further investigation, and limited research resources, one solution is to encourage stakeholders to participate in decisions regarding the prioritisation of topics for future research. Research priority setting methods can assist researchers and policymakers to effectively target research that has the greatest potential benefit [11,12], with a number of research funders incorporating the findings into their prioritisation processes [13]. Recent priority setting partnerships [14] have focussed on identifying priorities for research into the treatment of specific age-related health conditions [15,16]. However, care provided in care homes is unique as it encompasses a range of conditions and incorporates aspects of social care as well as healthcare. The aim of this study was to develop an informed set of research priorities within the care home setting. Care home staff were selected as the 'expert panel' as they have expertise in caring for older people in care homes [17] and a unique perspective not shared by the wider multidisciplinary team during limited visits or appointments. There is also a strong relationship between engagement of stakeholders in the planning and design of research and the subsequent quality, utilisation and outcomes [18,19]; therefore, involving care home staff is essential in order to develop care homes as a research environment. --- Methods The Delphi method [20] is a structured process that uses an iterative series of questionnaires to gather information, and rounds are continued until group consensus is reached [21]. This widely used method [22] allows for the inclusion of a large number of individuals across diverse geographic locations and, unlike a face-to-face meeting, avoids the situation where a specific expert may dominate the consensus process [23]. However, it is not without its methodological difficulties. Commentators caution that it should be viewed as expert opinion rather than indisputable fact and that a clear decision trail is vital to ensure credibility [24]. Care homes providing nursing care and those without nursing care were included in order to maximise generalisability of the results. Incorporating diverse viewpoints, such as those from different care environments, is considered to improve the quality and acceptability of results in Delphi exercises [24]. Other stakeholders, such as care home residents, their families and friends, and healthcare professionals were not included as it was considered that their perspectives may be too heterogeneous to be combined into one priority setting exercise conducted entirely using remote survey techniques. A number of priority setting exercises have exclusively used a single group of healthcare professionals [25][26][27]. There are many differing forms of Delphi in existence, with few researchers using a uniform method of the Delphi technique [22]. This study used a modified Delphi approach, which utilised a combination of online surveys, postal questionnaires and workshops while retaining the essential elements of the technique: achieving consensus through using a forecasting process to determine, predict and explore group attitudes, needs and priorities [22]. The study was piloted with staff from care homes participating in a separate study conducted by the same researchers [28]. This project was conducted by the South East Wales Trials Unit as part of a portfolio of research involving the older person. Ethical approval was granted by Cardiff University School of Medicine Research Ethics Committee . --- Participant selection Care home staff were defined as those who considered themselves as providing care for older adults in care homes, which included registered nurses, care assistants and matrons/managers. Participants were identified through partner organisations and networks, such as the National Institute for Health Research Enabling Research in Care Homes programme [29] in England and Scotland who disseminated the information via email and newsletters, and care homes in Wales that had previously participated in research and who were, therefore, known to the researchers. Information about the project was also shared by websites that are commonly accessed by care home staff. Potential participants were invited to take part by completing an online survey accessed via a URL link, completing and returning a printed questionnaire or by attending a local workshop event hosted by Comprehensive Research Networks, part of the ENRICH network. --- Project design The survey was conducted across three rounds. Demographic data and method of completion of the survey were also recorded. --- Round 1: Elicitation of research topics Participants were asked to identify areas where they felt there were uncertainties or questions about the care provided on a day-to-day basis in care homes. Participants could provide as many or as few questions as they wished within a large free text space provided. --- Refining research topics/questions The 'raw' questions were collated, analysed and formatted by one of the researchers with a clinical background and an interest in acute care in older populations into researchable questions. A random 20% selection was also formatted in parallel by another researcher, a medical sociologist with an interest in patient-centred care , blinded to the refined question generated by the first researcher. These 'double assessed' questions were compared and, where significant differences were found in either the interpretation of the question or question wording, agreement was reached on the final refined question. Similar or duplicate questions were combined where appropriate. Questions that were considered impossible to formulate into a research question were removed. A pragmatic literature search was undertaken for each topic identified. Research questions that were considered to have sufficient existing evidence, and therefore not true uncertainties, were removed. The remaining 'long list' of questions was taken forward into the next round for building consensus. Round 2: Building consensus on priorities Round 2 was the interim stage, to proceed from a long list of research questions to a shorter list. The research questions were categorised by the identified themes, in order to provide structure and aid completion by participants. These were sent to participants via post or email as indicated by their stated preference in their response to the first round. The participants were asked to rate how much they agreed or disagreed with the statement 'This topic is very important to me' for each question, using a 5-point Likert-type scale, 1 being the most important and 5 the least important. Median scores and interquartile ranges were calculated for the participants' responses to each question. Median scores were calculated per question in order to characterise the answer category above and below which 50% of the answers fall. IQRs, which form the distance between the 25th and the 75th percentiles, were used to represent the spread of the data and to assess the level of consensus per question. Responses where the median was ≤2 with a small IQR were considered important research questions that have reached consensus. Those with a median ≥4 with small IQR were considered to have reached consensus on a lack of importance. The 15 most important questions were shortlisted for the third round. --- Round 3: Reaching consensus on priorities In the final round, the highest rated research questions from round 2 were randomly listed and the participants were asked to rank how much of a priority each research question was from 1 to 10 . Participants were asked to use each number only once, leaving those that they felt were not so important blank. Incorrectly scored or illegible responses were not included in the analysis. Responses were inversely scored and collated. Priorities were defined as the research questions receiving the highest total scores. --- Results --- Round 1 Eighty-three participants responded to the initial survey , providing 144 individual responses representing a mean of 2.32 questions per participant. Of note, 75.9% of these also provided demographic data and method of survey completion . No significant difference was found between participants providing high and low numbers of questions, or method of completion. Nine responses, which could not be formulated into a research question due to insufficient content or context, were removed. Fourteen were considered to be duplicate or identical to other questions and were removed. The 121 questions remaining were categorised into 18 themes . Just over a third were considered to already have sufficient evidence. A total of 76 research questions remained for prioritisation in the next round . --- Round 2 Forty participants responded to the second round, 95% provided some demographic data. Participants' responses showed a high level of importance across all 76 research questions, with few participants providing a response that they 'strongly disagreed' with the statement that the question was important . The 15 research questions receiving responses where the median was ≤2 and had a small IQR ≤1.52 were considered important research questions that had reached consensus . --- Round 3 Forty-three participants responded to the third round and all provided demographic data, with a further six questionnaires received which were incorrectly completed and excluded from the analysis. The top 15 ranked topics are shown in Table 2. A wider group than anticipated responded to the final round as a result of the link to the online survey being shared by interested individuals, groups and organisations to individuals who had not participated in the first two rounds but wished to be involved. The scores from these are not included in the main prioritisation findings but were analysed separately to assess the degree of consistency between the findings from the main cohort and two further groups: a similar group of 60 care home staff who had not participated in the previous rounds, and 33 professionals from both health and social care sectors including occupational therapists, doctors, social workers and care regulators. The results from these groups had a similar ordering to the original cohort of participants . --- Discussion This is the first study to establish research priorities for older people requiring long-term care in the UK. The top 15 research priorities identified by care home staff include questions on person-centred care, dignity, appropriate staffing levels, and training and support requirements for care home staff. A previous international survey of care home experts identified priority areas for future research, rather than specific research questions [30]. Although the authors note the heterogeneous nature of the nursing home population internationally, some common priorities with our study included a focus on the needs of cognitively impaired residents and palliative/end-of-life care [30]. The highest ranked priority in our study may have been as a result of recent policy developments across the UK, which have highlighted the importance of a more 'person-centred' approach within care services. Despite 'person-centred care' being common parlance in older person literature in the UK and internationally, there is a lack of consistency in how the term is understood. This broad theme may have been rated highly as it incorporated a range of philosophical and practical approaches to care, or it may have been due to its heightened prominence as a key aspect of quality care. Questions relating to staffing levels, quality and training were ranked highly in our study, which may reflect the persistent challenges in providing appropriate staffing and quality care. In contrast to the USA, few EU Member States have systematic compiling and reporting of key quality indicators for long-term care. However, the situation is changing, with more countries developing national, standardised quality measurement systems. End-of-life care is increasingly being provided in care homes. Residents in care homes are in the last years of life and often present with multiple health needs, cognitive impairment and particular palliative care needs due to their advanced age. Questions relating to early and appropriate discussions about end-of-life care, and the role of families and healthcare professionals in improving end-of-life care were considered important. --- Limitations Residents and their families and friends were not included as participants in this study. The majority of participants were care home managers, who may have less involvement in providing care for residents and whose views may not be representative of the wider group of care home staff. Care home mangers may have a heightened awareness of issues such as staff training and levels of staffing, and exposure to current topical issues such as person-centred care, in comparison to other groups of care home staff, which may have influenced the ranking of these topics. The relatively small number of participants meant we were unable to compare responses by different occupational groups or by care home type. Using a modified Delphi approach, there was a loss of participants during the three rounds, which may have impacted on emerging consensus over time. It was difficult to conclusively identify and track participants across every round, which may account for small inconsistencies in the demographic data reported. Responses from two additional groups showed a high degree of consistency with the original cohort of participants; however, the research questions had been determined prior to their involvement. Research topics identified by health and social care professionals, commissioners, care regulators and the broader research community working with care homes may differ significantly from those identified by the participants in this study. It is not known why participants allocated particular rankings. This may be due to some topics being considered lower in importance, less problematic or that participants felt there was less uncertainty about the evidence underpinning them. --- Conclusion A set of research priorities for older people in care homes have been identified by a key stakeholder group and endorsed by other professionals involved in their care. It is hoped that sharing these results with clinicians, researchers and funding bodies will help to begin the process of ensuring that the future research agenda can be focused on the areas of greatest need. Addressing research questions identified as priorities during this study may contribute to the development of a more evidence-based approach to care provision within care homes. Further research to identify the research priorities of other key stakeholders such as health and social care professionals, commissioners, care home residents and their friends and families is required in order to identify a more definitive set of priorities. --- Key points • An increasing number of older people are requiring longterm care, many of whom have complex healthcare needs. • Currently, there is little evidence basis for much of the care provided for older people resident in care homes. • Setting research priorities assists researchers and policymakers to effectively target research that has the greatest benefit. • The research priorities included person-centred care, dignity, appropriate staffing levels, and staff training and support. • This is the first study to establish a set of research priorities for older people in UK care homes. --- How can early and appropriate discussion with older people in care homes about end-of-life care be supported? 7 How can recruitment of carers with essential qualities such as compassion and empathy be improved by care homes? 8 How can best interest decisions made for care home residents with dementia be properly documented in care plans? 9 How can care homes be made to feel more like a home? 10 What is the public and media perception of care homes compared with other care settings, and what is the impact on care home staff attitudes? 11 What is the impact of levels of oral hygiene on the nutritional status of older people living in care homes? 12 How can families and healthcare professionals contribute to improving end-of-life care for older people in care homes? 13 What activities can improve the quality of life for care home residents with impaired vision or hearing? 14 How can the provision of visual aids enhance the quality of life of people with end stage dementia? 15 Can education strategies improve care home staff attitudes towards the use of power and authority in their relationship with older people with cognitive impairments? --- Supplementary data Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. --- --- Conflicts of interest All authors declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work. --- Funding The work was supported by the South East Wales Trials Unit as part of the development of a portfolio of research involving older people.

Background: currently, there is little evidence base for much of the care provided for older people in care homes. Given the wide range of topics that require further investigation, and limited resources, one solution is to identify the priorities for future research. Methods: a modified Delphi technique was used to identify research topics and develop consensus among care home staff participants. The survey was conducted across three rounds. Firstly to elicit topics that were considered by participants to require further research, secondly to prioritise the long list of research questions, followed by a third round to reach a consensus on the highest ranked 15 questions. Results: eighty-three participants responded to the initial survey, providing 144 questions. Following analysis and review against existing evidence, 76 research questions remained. Of note, 40/83 participants responded to the interim prioritisation round and 43/83 participants responded to the final round, which ranked the top 15 research questions by importance. Two other groups of health and social care professionals also participated in the final ranking. The results from these groups had a similar ordering to those of the original cohort of participants. Conclusion: this is the first study to establish a set of research priorities for older people in the UK care homes. It is hoped that sharing these results with clinicians, researchers and funding bodies will help to begin the process of ensuring that the future research agenda can be focused on the areas of greatest need. Further work to identify the priorities of other key stakeholders is required.

INTRODUCTION Over recent years, a substantial work has already been undertaken in HCI around design for reflection, spanning a range of applications including behavioural change [8,28], personal informatics [19], mental health [40] and emotional wellbeing [31]. However, while many of these works aim to lead to transformative reflection -i.e., eliciting change in behaviour or mental schemas -there is a clear gap in our understanding of how such in-depth reflection can be facilitated through technology . In particular, it is not yet clear what are the key ingredients/components of a reflective process Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page. Copyrights for components of this work owned by others than the author must be honored. Abstracting with credit is permitted. To copy otherwise, or republish, to post on servers or to redistribute to lists, requires prior specific permission and/or a fee. Request permissions from [email protected]. Instead, as Baumer [2] notes "prior work carries an implicit assumption that [just] by providing access to data that has been 'prepared, combined, and transformed' for the purpose of reflection, reflection will occur." Such a view of the reflection process, as purely triggered by providing 'information' about the situation is, however, in direct conflict with the underlying reflection theorists , who highlight the extensive support and scaffolding needed for transformative reflection to happen. As such, although for example a reference to Schön's reflection-in-action is common in most of these works , the intricacies of how people do reflect and how the reflection process can be supported through technology seems to be mostly missing from the HCI work so far. This paper aims to address this gap and argues for a framework to design for transformative reflection by highlighting the need to scaffold the reflection process, rather than assuming the ability to reflect is a trait that can be readily triggered by providing the relevant information. We develop this line of argument in four steps: We start by reviewing the concept of the reflective practicum, by Schön [33] as an articulation of mechanisms to scaffold transformative reflection, arising predominantly from Schön's empirical work in architectural studio settings. In essence, Schön emphasises the importance of the 'right sort of experience' for the learners, which is deliberately scaffolded through an interplay of curricular components. Second, we illustrate how these core aspects of the reflective practicum can serve as a useful sensitising concept [4] to help identify the mechanisms supporting transformative reflection in other settings. In particular, we retrospectively analyse the findings of two long term case studies unpacking the learning processes, challenges and opportunities for technology in two social-emotional learning contexts: masters counsellor training [39] and primary school education [36][37][38]. Third, this analysis enables us to extend the concept of reflective practicum into a framework to guide technology development in SEL. We do this by abstracting key strategies and curricular components across the case studies, particularly highlighting the considerations of what makes experiences the 'right sort of' experience for SEL learning, and identifying the roles technology can play in three identified curricular components . Finally, we illustrate how approaches to scaffolding transformative reflection similar to those described in the reflective practicum and our own case studies, can be found in other previous HCI work in varied settings, such as those supporting reflection of diabetes patients [21], eating habits [26], or within romantic relationships [41]. Overall, this suggests the potential value of reflective practicum framework as a lens to understand designing for transformative reflection also outside the immediate domain of social-emotional learning. --- RELATED WORK Over the last decade, HCI researchers have shown increasing interest in designing systems to support reflection. These have been fueled by the realisation of the key role that reflection plays in areas such as education [12], behavioural change [8], design for wellbeing [31,40], personal informatics [19], or reflective design [34]. These developments are further emphasised by a series of recent review papers , taking stock of the field [1,2,13]. As such, we do not replicate their synthesising work in what follows, and instead directly build on their analyses to motivate and set the gap addressed in this paper. While various conceptual and theoretical accounts of reflection co-exist across HCI work , there is a shared understanding that reflection can take multiple forms differing in its 'depth': from simple 'revisiting' of an event to 'transformative' reflection that leads to change in practice or understanding of why and what happened [1,13,22]. Such a transformative effect-i.e., leading to a change in behaviour or an insight-is what makes reflection a key process for education [6,18,22,32,33] as well as a crucial part of systems in behavioural change, personal informatics, and wellbeing. Despite more than a 75 HCI papers on reflection in the last 7 years [2], there is still a lack of understanding of how transformative reflection can be supported through technology. In particular, although it was raised as an open question already by Fleck and Fitzpatrick [13] in 2010, supporting transformative reflection was still seen as "the most difficult challenge for designers" in 2015 [1, p591]. As Baumer et al [2] point out, one possible explanation for this gap is that-for majority of HCI projects-"reflection was implicitly defined as something that would happen by providing the user with some type of information about a particular situation, and as a result the user would have a newfound awareness in the interventions domain of interest". Kay [17] goes even further to characterise the reflection strategy of many current systems as "show the user a graph and hope". While there are exceptions within the body of prior work that do not conform to this trend of triggering reflection through presenting data , to the best of our knowledge there is little systematic understanding in HCI of what transformative reflection entails, how it can be scaffolded, and how such a process could be meaningfully supported by technology. In contrast, the educational literature has long acknowledged the importance of reflection and worked to develop practical approaches to promote transformative reflection for the purpose of learning [22]. What connects many of the leading scholars in this area-such as Boud [6], Kolb [18], Moon [22,23], and Schön [32,33]-is the emphasis on the reflection process as requiring substantial scaffolding while being tightly linked to a learners' particular experiences. In the rest of this paper, we draw on one such approach: Schön's work on identifying the strategies to scaffold transformative reflection in what he labels a 'reflective practicum' [33]. Schön's treatment of how practitioners-particularly in the design studio-manifest and develop expertise through 'reflection-in-action' has been highly influential in HCI work, with the concept of reflection-in-action referenced in over 70% of research papers [2]. However, the associated idea of reflective practicum, as a set of strategies to promote and scaffold reflection-inaction, has received much less attention . Moreover, we argue that, in fact, it appears that much of the complexity underlying Schön's idea of reflection-in-actionsuch as the crucial intertwining of reflection as a discussion with the on-going experience-has often been lost in HCI applications. The aim of the next section is thus to draw out the key concepts and ideas underpinning the concept of reflective practicum, providing the articulation of reflective practicum as a sensitising concept driving the discussion in the rest of this paper. --- SCH -ON'S REFLECTIVE PRACTICUM It is as if the mentor said: "I can tell you that there is something you need to know, and with my help you may be able to learn it. But I cannot tell you what it is in a way you can now understand. I can only arrange for you to have the right sorts of experiences for yourself. You must be willing, therefore, to have these experiences". Donald Schön: Educating the reflective practitioner, p93 In Schön's description, reflection has both a crucial importance for helping the expert to orient and make sense of the unique situation they are facing, but is also also seen the method through which the experts develop their competence. In particular, a practitioners' expertise relies on patterns that the practitioner can, consciously or unconsciously, draw on and appropriate within the novel situation; and these patterns are learnt through earlier reflection-in-action . Importantly, reflection-in-action is strongly grounded in specific experience. Schön describes it as necessarily including a 'discussion' as part of the experience, in which the expert probes and works 'with' the situation to transform their understanding of how a solution might look. As such, doing and thinking are complementary in reflection-in-action as "[d]oing extends thinking in the tests, moves, and probes of experimental action, and reflection feeds on doing and its results. Each feeds the other, and each sets boundaries for the other." [32, p280]. In other words, though reflection-in-action the actor 'experiments' within the situation by acting on the experience with the expectation of a particular reaction , and analyses the reaction-the 'backtalk'-of the situation to inform further action . Reflection-in-action occurs while we are still engaged with the situation; as such, one of it's core aspects is the opportunity to experiment with and affect the on-going activity. In contrast, we may reflect on action by "thinking back on what we have done in order to discover how out knowing-in-action may have contributed to an unexpected outcome" [33, p26]. For Schön, the defining characteristic of reflection-on-action is that it has no direct connection to the present activity. It is thus closer to the reflection process as understood in the work of other reflection theorists, such as Kolb's experiential learning cycle [18], as well as the post-hoc reflection processes in learning that Boud emphasises in his work [6]. As we will see in the following sections, the distinction between reflectionin/on-action is complex for reflection within SEL curricula and a subtle combination of both is key. --- Developing expertise -the 'reflective practicum' Going beyond describing the reflection-in-action as the defining component of expertise, Schön also looks at strategies by which reflection-in-action can be taught. He draws on the architectural design studio and the training process in psychotherapy supervision as two key examples to identify a set of learning processes-the reflective practicum-that underpin the learning in these two domains. In the rest of this section, we outline the main characteristics of reflective practicum: What is a reflective practicum Schön characterises the practicum as multiple layered settings whose sole purpose is the structuring of the learning process: "In a context that approximates a practice world, students learn by doing, although their doing usually falls short of real-world work. They learn by undertaking projects that simulate and simplify practice; or they take on real-world projects under close supervision." [33, p36] As such the practicum is seen as a 'virtual world' that is that is free of the risks of the real one. This 'virtuality' of the practicum is crucial for the learning processes to happen: it provides the opportunity for safe exploration as well as structures the tasks so that the core aspects of the learnt competencies are highlighted. It seeks to enable students to "experiment at low risks, vary the pace and focus of work, and go back to do things over when it seems useful to do so." [33, p170] As such, it frames the activity as happening within a particular 'we-do-this-for-learning' mindset, which is crucial for the reflective engagement with the experience. --- Paradox of learning by doing The paradox of supporting students' reflection-in-action rests in the fact that the students do not, at first, "have the necessary mental concepts so that they cannot understand what they need to learn; and can learn it only by beginning to do what they do not yet understand" [33, p93]. The mentor's-and more broadly the practicum's-role is in arranging the right sorts of experiences for the students [33, ibid]. This points to what we argue is the key characteristics of reflective practicum: as reflection-in-action and the underlying expertise cannot be directly taught to students, the role of the practicum is to arrange the right sorts of experiences for the students. In other words, active engagement with the experience is necessary on part of the learner and the practicum is there to carefully scaffold the learning experiences so that these can successfully grasped by the learner. In outlining the structures by which practicum accomplishes this scaffolding, Schön strongly emphasises the mentors' role. In his view, it consists of two equally important parts: they need to scaffold the 'right sort' of experiences for the learner through well chosen tasks; but then also support the reflection-in-action process on these experiences so that the learner can learn. As such, the process is "more like coaching than teaching" [33, p157] in that the role of the mentor is in providing modelling and an opportunity for a dialogue around student's experience. It is this 'in-action' feedback and support that is used as means to scaffold students' attempts at reflection-in-action; and is thus seen are instrumental to successful learning on part of the student. As Schön says, "whatever the coach may choose to say, it is important that he says it, for the most part, in the context of the students doing. He must talk to the student while she is in the midst of a task " [33, p102]. The scaffolding of reflection-in-action itself thus comprises three essential features: it takes place in the context of the students attempts to do the activity, i.e., their immediate experience; it makes use of actions as well as words; and it depends on reciprocal reflection-in-action between the student and mentor. --- Reflective practicum -summary Based on the literature above, we now summarise Schön's concept of reflective practicum into a set of core points: ? The key assumption that the expertise cannot be taught to the learners, but needs to be actively constructed by the students who rely on the practicum to facilitate and scaffold their experiences to lead to learning. ? Reflective practicum is a setting designed specifically to generate a particular sort of experiences that allow the students to explore by doing, through an enmeshed interplay of action, imitation, and reflection leading to further action. ? This includes appropriate teachable moments that provide the experience to work with; and the processes of reflection that facilitate the act of 'grasping' of the experience and transforming it into learning. ? In particular, the reflective curriculum provides a 'virtual space', where the core of the task-to-be-learnt can be explored/practiced repeatedly , but without the adverse effects of failure. The main difficulty is then in facilitating activities that include the core characteristics of needed expertise but without the full associated pressures of the real-world. ? Such 'right sort of experiences' often do not arise automatically; they are generated through an interplay of the varied curricular components that comprise the practicum. ? In Schön's apprenticeship contexts, the curricular structures have predominantly relied on the role of the mentor: mentors played an instrumental role in facilitating meaningful teachable moments through well-selected tasks while at the same time providing modelling and in-the-moment scaffolding to help students make sense of the resulting experience through reflection. Before moving onto the case studies, we briefly mention two aspects that are missing in Schön's account but would be beneficial for HCI applications: First, as a learning theorist, Schön's interest was predominantly in understanding how the existing curricula work. As such, his framework does not directly address how technology might be drawn in to augment or support reflective processes. Second, the reflective practicum as described by Schön relies strongly on mentors' in-the-moment support as the main curricular structure. This is mainly as both architecture and Freudian psychotherapy training come with a strong apprenticeship focus. As such, other possible curricular components are not described in detail. We will touch on both of these aspects in the rest of the paper. --- SEL CASE STUDIES We begin by briefly reviewing the two SEL case studies, offering an overview of each and summarize the key findings as they relate to supporting reflection. In particular, we draw on two long term projects aimed at understanding the learning processes, existing challenges, and the opportunities for technology within: ? a masters counselling course, where the future therapists are going through an in-depth, sophisticated training aimed to develop expert social-emotional competencies [39]. ? universal prevention programs in primary schools, where the students are taught basic life skills, such as self-awareness, self-regulation or relationship skills [36][37][38]. The case studies presented here will help us further two arguments: First, the next section will use these empirical observations to exemplify how reflective practicum sensitises to particular aspects of the reflection process that have not been unpacked by previous work [36][37][38][39]; as well as provides a conceptual framework that allows us to identify the strategies through which reflection is scaffolded across these two very diverse contexts. We note that such fit of Schön's within the SEL context was not immediately apparent as neither the counselling nor prevention science are directly building on or even referencing Schön. Second, such analysis allows us to extend the concept of reflective practicum with considerations of the possible roles for technology, given that both of the case studies included user-centred design methodologies and focus on meaningful technology involvement as core part of the research process. Given the challenges with developing SE competencies-such as their intangibility, embeddedness in social interaction, and the inherent role of emotion that disrupt reflection-we will see how the curricula draw on a broad set of evidence-based strategies and mechanisms to both generate meaningful 'teachable moments' and scaffold students' reflection on these. In doing so, the case studies exemplify how that the opportunity for transformative reflection was deeply tied with the underlying experience of the learners; and how such experiences were painstakingly designed for and orchestrated by the curriculum setting. Similarly, neither curriculum took the learners ability to reflect on their experiences for granted and it was instead carefully scaffolded within the experiences through an interplay of curricular components. --- SEL in Counselling The first case study, drawing on [39], is unpacking the learning processes of a person-centred counselling masters course at a major UK university. In what follows, we briefly summarise the aim of the curriculum, the methods used to teach students, as well as the challenges and opportunities for technology identified by the previous work. The counselling curriculum has a strongly experiential focus, emphasising the importance of an in-depth understanding of the client and well-tuned self-awareness ability. The program had very explicit processes and tools to promote reflection of students, always closely tied to a particular experience . For example, the 'Interpersonal Process Recall' was used throughout the course. IPR is a traditional technique developed by Kagan [16] in the 1970s, aiming to facilitate counsellors' deep reflection on, and awareness of, their own feelings and thoughts during counselling sessions 1 . However, these were complemented by carefully designed learning sessions , as well as intricate set of social norms encompassing all interactions . The aim of such curricular scaffolding was two-fold: first, to create 'real' experiences for the students, whether that was working with actual emotions of a peer client, or getting to grips with their own emotional states facilitated by a particular lesson; and second, to then allow for experimentation and reflection on own behaviour in the safe learning space established by the curriculum. To allow students to do so, the full first year of the course was dedicated to developing their reflective abilities, so that they were able to process and analyse their experiences in detail, even without an in-the-moment support from the mentor. In terms of existing challenges and possibilities for technology support, the study identified a key issue around the difficulty to 'close reflection loops' within the interpersonal settings of client-counsellor sessions. In particular, fundamental difficulty in the counselling practicum lies in directly supporting reflection-in-action within the practice counselling session experience. The counsellor cannot step out of the role to ask the client if "they wouldn't mind going two questions back and taking it from there to try another way of framing it", as that would break the emotional realness of the situation. To limit impact of this mismatch between what is possible and what would be preferable, the curriculum in our case study focused on extending the experience beyond the practice session. Such processes so far relied on scaffolding students' reflection through 're-living' the coun-selling situations including various ways of engaging with the video replay, albeit mostly relying on pen-and-paper methods. The designed technology took up this challenge to extend and deepen this reflection process through a custom made annotation tool. The aim was to allow for 'localised reflection' , as well as bringing in client's reflection as a way to sense check and close the reflection loops. These then built on the reflective support structures such as the IPR to help counsellors to return as closely as possible into their experience within the session; reflecting on their assumptions at that time as well as identifying the reasons for the decisions, misunderstandings, or blunders in the session. --- SEL in Primary education The second case study focused on understanding the learning strategies and challenges of existing social emotional curricula in education; including review [36], interview study with experts [37], and user-centred design of a pilot system [38]. Overall, SEL curricula are part of universal prevention programs in education, so working with all kids in primary schools. Coming from a long line of evidence-based research , such curricula are now in more than 44% of US schools [7]. The skills taught in SEL curricula are those that have been identified by psychologists and educators as crucial not only to development in childhood and teenage years, but more importantly as key skills for adult life, such as selfawareness, self-management, social awareness, relationship skills, and responsible decision making. The curricula depend on mostly in-class, scripted lessons delivered over longer periods of time . The learning strategies strongly rely on role-plays, inthe-moment coaching from an adult such as the teacher, and 'mental tools' [42]. Mental tools are simple cognitive or behavioural strategies designed to serve as an internal scaffolding that allows the learners to recognise and work with the naturally occurring situations as teachable moments: if working well, they provide a space to take a step back, reflect, and re-engage with the situation only after it has been processed. An example of such mental tool is the 'Turtle technique' [29]. The children are taught to 'withdraw into their shell' at specified occasions such as when they feel increasingly angry. This is followed by a relaxation phase, where specific muscle groups are tensed and released. Once this technique is mastered, children discuss appropriate alternative strategies for dealing with stressful situations, now that they are able to consciously reflect and react to them. The aim is that-through the use of these tools-the children will re-interpret the on-going real-world situations as learning experiences and opportunities for applying the developing competencies. In addition, the mental tools serve as external triggers that can be tapped into by teachers/adults more broadly, if the child has not appropriated these fully. This points to the strong reliance on the social support structures provided by teachers/adults more broadly, which we turn to below. As the role-plays and other scaffolded interactions are not seen as 'real enough', the curricula rely on complementing the in-class role-plays with appropriating everyday moments from the naturally occurring situations . This however brings issues with such natural situations lacking any explicit scaffolding . As such, there is a strong risk of the situations becoming 'too real', overwhelm the student, and lead to the loss of the learning focus . As such, out-of-lesson learning is still strongly dependent on coaching by an adult , who provides the on-going cues, prompts and reminders needed by learners. The key challenge is then in the lack of scalable techniques to get beyond classroom-based learning and support the in-themoment reinforcement and scaffolding in everyday settings, as these are needed for the skills to be transfered from in-class intervention to practice. To explore one possible solution, the technology probe in [38] aimed to provide a shared experience for parents and children together through an interactive story. A key part of the design was focused on facilitating the in-the-moment scaffolding role of the adult to help children reflect on the experience that the interaction generated. --- HOW IS TRANSFORMATIVE REFLECTION SCAFFOLDED IN SEL? We now apply Schön's reflective practicum as a sensitising concept to understand the reflection processes underpinning learning across the two SEL contexts, by emphasising two key aspects: first, the focus on understanding what constitutes 'right sort of' experience for the learners; and second, the interplay between different scaffolding structures within the practicum that then generate such experiences. Through this discussion, we suggest that the reflective practicum serves as a useful sensitising lens to help us dissect the reliance of SEL curricula on carefully facilitated sets of experiences for learners as well as identify the strategies through which reflection is scaffolded across the two settings. The resulting framework then prepares ground for the next section proposing how such analysis can inspire and guide future HCI work in this area. --- Characteristics of the 'right sort of' experience One of the key arguments in Schön's work is that only the 'right sort of' experiences can be expected to lead transformative reflection. For example, the 'right experiences' within the architectural studio were seen as act of "reflective designing" [32, p79] : a combination of the students' active involvement with a particular design case they struggle with, such as sketching a solution to a design problem; with their reflection scaffolded by the in-the-moment support from the mentor; and doing so in a 'safe space' where experimentation was encouraged and effect of failure low. In other words, --- Real%enough But%not%too%much% The$experience$must$be% meaningful%for%learning: The$experience$must$be$ available%to%be% reflected%with/on: In$SEL$this$means$eliciting$actual$ emotions$and/or$interpersonal$ interaction$for$the$learners.$ This$requires$the$opportunities$ for$reflection>in/on>action,$ which$includes$the$ability$for$ safe$exploration$of$alternative$ actions$and$thus$'closing$of$the$ reflective$loop'.$ %Characteristics%of%the%'right%sort%of'% SEL%experience it was the experience of grappling with a design problem that felt hard to do, coupled with access to scaffolding such as the mentor's in-the-moment feedback that allowed for reflection as part of the experience, while knowing it is embedded in the low-risk 'virtual world' of the curriculum. Applying this analytical concept to the SEL learning, we argue there are similarities between such 'real-enough but not-tooreal' experiences that Schön draws out and the SEL contexts: In particular, we propose that the 'right sort of' experience in SEL can be then characterised to include an element of tension between eliciting emotions and/or experience of interpersonal interaction that feel real, but at the same time not too overwhelming so that it can still be approached with a learning mindset and reflected upon. We see this 'real-but-not-too-real' quality as fundamental to what Schön describes as the virtuality of the curriculum. In the architectural studio that might mean that a 'failed' design leads to an enlightening design crit session with the mentor rather than a loss of money and customers. Analogously for SEL, such virtuality might for example suggest that if one learns about dealing with conflicts-and thus must experience, to some extent, a real conflict with another-both parties preferably understand this is a learning situation, done for the purpose of competency development, and will not generate hard feelings regardless of the outcome. We can interpret the SEL curricula as aiming to resolve this tension between real-but-not-too-real experiences by careful balancing of the emotional strength of the experience for the learners. As shown within the case studies, this then means generating or appropriating situations where the learners themselves experience actual emotions or interactions, while preventing the emotional strength of these experiences from spinning out of control . One example of such careful balancing embedded within the structure of SEL curricula can be seen within the counselling practice sessions . On one side, the emphasis is placed on discussing personal issues in the peer-client experiences in order to create a 'real' counselling scenario. That is, the mentors make clear that very little can be learnt unless the peer-client is willing to talk about matters that emotionally affect them, giving the peer-counsellor the chance experience and work with situations that are emotionally real for the client. On the other side, however, extensive care also goes into how these sessions are scaffolded and perceived by the participants to ensure the learning goals of the generated experience are kept. This includes multiple mechanisms that reinforce the learning focus at various points, such as the learning contract of 'being here to help each other', the immediate post-session debrief, the use of reflection processes such as IPR, as well as the availability of mentors should the 'issues get out of hand'. In highlighting the 'real-but-not-too-real' experiences, we need to clarify what 'real' means in the reflective practicum context. In line with the strong focus on learners' experiences, we suggest it is the notion of perceived realness which is key here: what matters is if the emotion or social interaction 'feels real' to the learners rather than whether the experience has been staged or naturally occurring. For example, if one wants to learn to self-regulate, then the essential feature of the learning experience is a strong enough emotion so that controlling it becomes an issue. While appropriating moments of stress in the real-world, such as everyday conflicts within the classroom, is one possible option, a well made horror-game can provide a similarly real feeling of stress and pressure for the learner, albeit in actuality completely staged. In the architecture training, the students need not work on designing houses that will be built; instead what matters is that the assignment creates meaningful design choices to be solved. Overall, across both domains the aim was to always work with the 'most real' situation that can be still grasped as a 'teachable moment', rather than being swept away by it. The next section discusses how such 'right sort' of experience is then generated through the learning structures of the practicum. --- Three scaffolding components of reflective practicum Schön's analysis highlights how the reflective practicum comprises a range of structures that all contribute to facilitating learning experiences for students. For example, Schön argues how the architectural studios have "evolved their own 'rituals', such as master demonstrations, design reviews, desk crits, and design juries" [33, p43] within which the crucial coaching role of the mentor is embedded. In other words, the reflective practicum can be seen as an interplay of different types of components, all working together to generate the 'right experiences' for the students and scaffolding their reflection on these. So how does this view map onto the empirical observations of the two SEL curricula? Similarly to the settings described by Schön, the 'right sort' of experiences did not appear 'automatically' in neither the SEL in education nor counselling curricula; instead, a number of specifically designed curricular components scaffold experiences and the associated reflection process. We unpack the characteristics of such components within SEL case studies into the explicit components in the practicum , the social components , and the personal components . Moreover, this distinction will further help think about the possible role of technology as part of reflective practicum. Figure 2 provides a summary diagram of these three components and their relation to the characteristics of the SE learning experience. --- Explicit components We propose that the role of the explicit components can be interpreted as directly re-structuring/shaping the experiences of the learners through tasks or specific 'tools' to scaffold reflection. For example, tasks such as the role-play vignettes in education, the counselling practice sessions, or a design crit in architecture provide boundaries on which experiences can arise for students. Similarly, reflection tools such as the IPR process in counselling or mental tools in education structure particular ways of working with the experience and mediate how learners relate with the world. As such, explicit structures include both shaping the situations through which experiences are generated, but also providing explicit scaffolding processes to facilitate grasping of these through reflection. --- Social components In contrast, the role of the social components can be seen as to provide a supportive learning environment and a set of social resources the learners can draw on as they proceed with the training. This might include establishing specific norms and access to expert in-the-moment feedback and peer support. Specifically, strong social structures play an important role in creating a safe practicum space in which the other training components are embedded. This includes the expectation that the interaction will be seen through the learning lens, i.e., understood and supported by others as 'learning material'. --- Personal components Finally, the personal components correspond to the learners' internal qualities that are crucial for the learners' grasping of the experience. This includes the students' motivation to actively engage with and learn from their experience, as well as their existing abilities to reflect-in/on-action. For example, the practice sessions within counselling curriculum strongly rely on the presumed abilities to reflect that the students are expected to develop earlier . --- DESIGNING FOR TRANSFORMATIVE REFLECTION IN SOCIAL-EMOTIONAL LEARNING CONTEXTS We argue that the lens of the reflective practicum can serve as a guide to designers aiming to develop a technology-based system for transformative reflection, in the context of SEL. Building on the understanding of how reflection is scaffolded in existing curricula, we suggest a two step process: The first step offers a set of questions aimed to help understand characteristics of the 'right sort of' experiences that are likely to be conducive for transformative reflection. The answers to these can inform the initial design brief to be taken to the next step. Second, we propose that the three curricular components highlight possible roles that technology might play in scaffolding the selected experiences. In particular, these aim to translate the strategies used in the curricular components into plausible directions for technology scaffolding. Step 1: Reflective experience space This set of sensitising concepts highlights the decisions and considerations that the designers might find useful to take into account when scaffolding transformative reflection in the SEL context. -What constitutes a 'real-enough' experience? - The three questions below emphasise what we see as core aspects of the tension between experiencing a strong-enough emotion/interpersonal situation while keeping the reflective focus needed for learning. Q1: What characteristics make the experience 'real-enough'? This question aims to help the designer explicate what are the "essential features of a practice to be learned" [33, p170] that will make the experience seem 'real' for the learner. Given that SE competencies are normally embedded in complex social settings, it is important that designers unpack the minimal set of features that are essential for a meaningful learning experience . For example, as mentioned earlier, in learning to self-regulate it is the strength of actual emotion perceived by the learner that is importantthis is regardless of whether this is triggered by a scary movie, a recollection of a memory, or a real-world event such as a conflict with a significant other. Q2: How 'real' should the experience feel? We noted above how the curricula endeavoured to create the 'most real' situation possible that still allows for a learning focus rather than being swept away by emotions. Thinking of experiences as being positioned along a 'perceived realness continuum' is useful in understanding the type of experience and the associated learning trajectory the system/intervention aims to facilitate. Again we note that it is the 'felt realness' that matters, rather than whether or not the experiences are directly embedded in the real-world settings. Q3: How much balancing support should be available We saw how the existing curricula carefully balance the perceived 'realness' of the experience through multiple mechanisms, such as adding scaffolding to structure the experiences or facilitate the reflection process that the learners should go through around these. This emphasises the focus on the mechanisms of transferring the learnt competencies from in-class or otherwise externally supported context to real-world unsupported situations by reducing the balancing support available to learners. This highlights decisions such as whether the aim is to transfer a competency mastered in one context to another , or the focus on creating a safe space with plenty of support where the initial seeds of competencies can be created. -What are the challenges to reflection? - We saw from both case studies how several inherent characteristics of SE experiences can make reflection-in/on-action difficult for learners. In particular, we emphasise the danger of emotional entanglement, the implications of intangibility of some SE competencies; and more broadly the inherent challenge in closing reflection loops as exploration of various responses to the same situation is often not possible. The extent to which each of the three challenges is relevant for a particular SE competency can markedly differ. However, if present, they might imply the need for additional scaffolding to support reflection and mitigate the effects. Q4: Is emotional entanglement likely? We discussed the danger of particular experiences becoming emotionally 'too real'; so real that the learners become entangled in the emotional states and lose the learning framing necessary for reflection-in/on-action. If this is the case, the existing curricula can provide an inspiration in how this can be mitigated through balancing the perceived realness of the experience through the support components. This might include providing the learners with in-the-moment scaffolding from a mentor or mental tools to be triggered in these situations, as well as recording traces of the key aspects of the experiences in order to facilitate reflection on the 're-lived' experience. Q5: How directly visible/tangible is the process of 'doing'? We saw how many of the social-emotional competencies are ephemeral and intangible. This makes them hard to model effectively for the teachers and similarly difficult to grasp for the learners. For example, the experience of being 'self-aware' has some visible implications , but the process of 'becoming self-aware' as well as the work that goes into it remains hidden. If this is the case, additional scaffolding might be needed to help learners both 'see' what the mentor does as well as make their own reflective processes more tangible. Q6: How easy is it to close the reflection loops? Social-emotional situations can be a highly continuous flow of action, and thus do not allow for exploration of multiple possible responses within a single situation. As such, it may be difficult for students to 'close the reflection loops' quickly enough to understand how their current behaviour works/doesn't work, and what might be the alternative approaches. Under such circumstances, this suggests the need for the practicum to either generate multiple highly analogous situations if that is possible; or provide scaffolding to extend the reflection phase beyond the situation itself . -How are the experiences achieved? - The case studies point to two main approaches through which SEL curricula facilitate the 'right sort of' experiences for the learners: The first corresponds to setting up of a particular situation that is likely to generate such 'right' experiences. Examples are the role-plays in education or the practice counselling session in counselling. The second relies on providing support so that the learners can appropriate real-world situations into the context of the curriculum, such as the coaching expected from teachers or parents within the SEL in education, or the supervision model in counselling. In effect, this re-interprets otherwise unsolicited experiences into teachable moments. These two approaches can be interpreted as bringing complementary benefits and challenges: Generating the experiences allows for good control and on-task support for the learners, but might struggle with eliciting real-enough experiences once the learners pass beyond a certain competency level. For example, recall the need of education curricula to move beyond role-plays. In contrast, aiming to appropriate real-world moments requires the curriculum to be much more opportunistic and presents difficulties in providing the necessary scaffolding for reflection and balancing emotional realness within the real-world settings. Step 2: Technology design space Seeing the questions from the previous section as leading to the design brief, this section illustrates how the reflective practicum can help unpack the design space for scaffolding the selected experiences. We structure such discussion independently for explicit, social, and personal practicum components, as each of these suggests particular mechanisms to scaffold the 'right sort' of experience for the learners, and thus also the prospective roles for technology systems. -Explicit components - The explicit components directly re-structure and shape the experiences of the learners through tasks or specific 'tools' to scaffold reflection. Looking across the case studies, we propose that these components can be further interpreted as addressing three possible roles: structure tasks or social interactions to generate particular experiences; provide mechanisms to appropriate real-world experiences as teachable moments; directly scaffold the reflection process. Each of these then suggests a particular role for technologies in support of transformative reflection in SEL, as well as underlying strategies and mechanisms that could be incorporated into technology-based systems. We discuss each briefly below. --- R1: Generate emotional/interpersonal experiences Both SEL in education and counselling relied on highly structured tasks that helped generate experiences for learners. These might have taken the shape of simple vignettes and role plays, as well as the intricate structure of practice counselling sessions. This points to the potential technology might play in facilitating emotional/interpersonal experiences such as through interactive media [3] or games . For a specific SEL example, the system developed in [38] used an interactive animated story to scaffold a particular emotional situation for the parent and child to work with. --- R2: Appropriate the naturally occurring experiences Components helping to appropriate naturally occurring instances as teachable moments were present in both counselling and educational settings. Such components supported learners in identifying the teachable moments , balancing the emotional realness of the situation , or making it available for reflection later . Each of these aspects could be addressed by the emerging wearables and other UbiComp technologies: sensor-based systems could help identify key situations as well as trigger self-regulation strategies , as well as collect traces that create 'time-windows' into the experience for future reflection. --- R3: Directly scaffold the reflection process While the previous two strands focussed on facilitating access to the underlying experience, this strand of explicit components aims to scaffold the reflection process on that experience. Both education and counselling curricula relied on tools that emphasise or problematise particular aspects of experience , as well as providing structured ways of working with traces to revisit and 're-live' the underlying experiences. The implications for possible roles of technology are for example by thinking about systems that can deepen the link between reflection and experience in one of two ways: by embedding the reflection scaffolding into the experience itself ; or through extending the possibilities to work with a trace of an experience post-hoc . -Social components - The role of social components is to provide a supportive learning environment through enabling a set of social resources the learners can draw on as they proceed with the training. In contrast to the explicit components, the focus of social components therefore shifts from directly affecting the learners' experiences to providing support to others who support the learning. In particular, the common strategies across SEL curricula can be interpreted as either supporting 'in-the-moment' coaching, as exemplified within the education settings; or the more diffuse set of social norms that promote reflection and learning processes from situations that happen in the space . This suggests two example roles for technology in this space: R4: Scaffolding mentors' scaffolding role The scaffolding role of the mentor is a key component across both SEL contexts. The emphasis is then on the need of mentor's own competency through which they model and facilitate reflection-in-action. This suggests potential for technology to scaffold this role for available-but-untrained mentors ; as well as providing support so that mentors become more effective such as through streamlining the scaffolding process. For an example of the former, the system developed in [38] was deliberately designed to support parents with prompts and questions to structure their interaction with children. For the latter, [37] provides mentors with tangible record of students reflection with the aim of making it easier and quicker to provide in-depth feedback during a one-on-one session with the student. R5: Support establishing learning culture and peer support The analysis of both SEL contexts has highlighted the importance of the social support grounded in learning culture and direct peer support in doing so . We argue that while such social norms and support are beneficial for any learning, they are of particular importance for SEL, where most teachable moments require the presence and interaction with others. Prior work in HCI suggests that technology could facilitate such social support both within existing peer groups , as well as connect networks of strangers together around a single cause . -Personal components - The personal components correspond to the learners' internal qualities that are crucial for the learners' grasping of the experience. This includes the students' motivation to actively engage with and learn from their experience, as well as their existing abilities to reflect-in/on-action. As such, we see these as much harder to directly affect by technology than the other two sets of components. In fact, limitations of personal components in the target user group might suggest the need to compensate for these through explicit/social components, such as the reliance on coaching and mental tools in SEL in education. --- R6: Supporting motivation to engage That said, we see opportunities in technology-based systems to facilitate motivation to engage for the users: for example, gamification elements have been shown to be successful to increase motivation in other contexts [9,35]; and there might be potential for technology-based short-term interventions that reduce internal barriers to action, such as those building on mindset interventions [25,43]. --- DISCUSSION: MOVING BEYOND SEL CONTEXTS This section aims to extend the argument by illustrating how aspects of reflection scaffolding similar to those described by the reflective practicum framework in SEL can also be seen in other HCI work. As an example, we discuss three otherwise unrelated HCI projects, coming from areas of diabetes management [21], healthy eating behaviours [26], and romantic relationships [41] 2 . We suggest that the reflective practicum framework proposed here provides a language to revisit these studies, helping to identify similarities in the underlying design strategies through which reflection is scaffolded in their localised contexts. Moreover, we conjecture that such similarities in successful designs could reflect shared mechanisms through which transformative reflection might work across domains. That is, similar to how Schön's observations of the learning process across architecture, engineering, consulting or music [32,33] can be translated to social-emotional learning contexts, we argue that these are applicable to a range of other areas that aim for transformative reflection. In line with the key features of the reflective practicum, each of the three systems is designed to deliberately scaffold particular experiences for users, incorporating active engagement with these as the crucial part of the design for reflection: ? In MAHI [21], the users are newly diagnosed diabetes patients, enrolled in an educational program helping them manage the new limitations. The MAHI system helped patients capture key measurements associated with what happened and most importantly engage in sense-making on this experience, with asynchronous feedback from the educators. The authors draw out how this 'articulation work', scaffolded by the system, led to deep reflection and, over time, marked shifts in how patients viewed and understood the implications of their actions [20, p121]. ? Community Mosaic [26] is designed to help underprivileged communities eat healthy food. The design was driven by a strong collectivistic focus, with the users asked to take photographs and descriptions of food they are preparing to inspire others in the community to eat healthier. Parker draws out the notion of 'reflectionthrough-performance' as the underlying design principle: she showed how the act of crafting a message for the 'unseen audience' served as a strong scaffolding for reflection, making the participant go through a process of looking at their behaviour from the 'others' perspective. ? Finally, the Lover's box by Thieme at al [41] examines how a digital artifact can scaffold reflection for partners in new romantic couples. The design combined a physical artifact and video messages that participants create for each other, with the support of a video artist. The authors argue that the 'principal vehicle for promoting reflection was the creation, exchange, and sharing of video messages', further mediated by the interaction with the video artist, who served as a crucial 'component of the reflection system'. Each of the designs can be interpreted as a combination of explicit, social, and personal components, providing similar mechanisms for the scaffolding of experience and reflection as in the social-emotional contexts: for example, the design of the 'task' in MAHI-linking the measurements and food logs with personal annotations-helps users appropriate particular experiences as teachable moments they can reflect on , while providing specific instances for modelling and support from the mentor . The system then relies on the strong inherent motivation of the participants who struggle to accommodate their newly diagnosed illness; and supports the development of their competencies to reflect on and make sense of their experience over time . Overall, these observations suggest that even if these authors do not reference each other, work in different contexts, and use different design strategies, seeing their work through the reflective practicum lens can point to similarities in the underlying design strategies through which transformative reflection is accomplished. As such, these systems can be interpreted as providing additional exemplars of practical instantiations of the strategies underlying reflective practicum, further populating this design space. --- CONCLUSIONS This paper draws on the combination of Schön's reflective practicum and two SEL case studies to argue how the process of transformative reflection is carefully scaffolded in two well-established training settings. Using the core aspects of the reflective practicum as sensitising concepts, we abstracted the strategies and curricular components that provide such scaffolding, and suggested a framework of questions and roles for technology that might guide designers in designing for transformative reflection in SEL. We argue that this design framework could be also used in contexts beyond SEL, emphasising the need to move past triggering reflection on data and toward scaffolding reflection within experience if transformative reflection is to arise.

Designing for reflection is becoming an increasingly important part of many HCI systems in a wide range of application domains. However, there is a gap in our understanding of how the process of reflection can be supported through technology. In fact, an implicit assumption in the majority of existing work is that, just by providing access to well-selected data, in-depth reflection can and will occur. To counter this view, we draw on Schön's notion of reflective practicum and apply it as a sensitising concept to identify the complex interplay of factors that support transformative reflection in the context of two social-emotional learning (SEL) studies. The results highlight the need to carefully scaffold the process of reflection, rather than simply assume that the capability to reflect is a broadly available trait to be 'triggered' through data. Building on this analysis, we develop a conceptual framework that extends the concept of the reflective practicum towards identifying appropriate roles of technology to support transformative reflection. While our case is within the context of SEL, we argue that a deeper understanding of these opportunities can also benefit designing for reflection in other areas.

Background Spontaneous abortion, also called, a miscarriage, is considered as poor Sexual and Reproductive Health outcome with higher consequences [1]. Around 23 million spontaneous abortions occur annually, equating to 44 pregnancy losses every minute [2]. Women at higher risk of pregnancy loss include those under the age of 20 or over 35 years, particularly those who experienced intimate partner violence, have a very low or very high body-mass index, have a history of miscarriages, smoking, stress, or are exposed to pesticides and pollution [3]. These issues are common among people of lower and middle-income countries especially urban slum dwellers, due to inadequate understanding and access to sexual and reproductive health rights -related information and services [4][5][6][7]. Spontaneous abortions have severe psychological impacts partly because they are unexpected by nature and have multifaceted impacts [8]. Depression and anxiety are the most common mental health conditions among women from both LMICs and high-income countries who experience spontaneous abortion [9]. In Mexico, 41.70% of women who experienced spontaneous abortions had depression and anxiety [10]. A large scale case-control study conducted in China also reported anxiety and depressive symptoms among women with a history of spontaneous abortions, and the risk was higher among those who had recurrent miscarriages [11]. Another Chinese longitudinal study reported that 55% of women stated depressive symptoms three months after the spontaneous abortion [12]. This was also found to be the case in the United Kingdom, where a similar group of women exhibited moderate to severe anxiety and depressive symptoms [13]. A systematic review reported the major risk factors for depression and anxiety among women with spontaneous abortions [14]. A review stated anxiety was common among women with a history of poor mental health, lower spousal support, no children, a history of miscarriage, and unplanned and assisted pregnancy. Along with these factors, depression was also found among women of younger age, poor relationships with partners and a history of infertility [9]. Despite the aforementioned burden of depression and anxiety among women experiencing spontaneous abortion reported worldwide, no previous evidence has been found in Bangladesh that interlinked these mental health issues among women with spontaneous abortion, especially those living in urban slums. In Bangladesh, about 7 million people in urban areas live in slums. They are especially at risk of poor health and are deprived of basic health care and family planning services [15,16]. Female slum-dwellers, often face socio-economic challenges, i.e., poverty, low education, violence, food security, and other social disadvantages that exacerbate mental health impacts [17][18][19][20][21][22][23]. Research is lacking in Bangladesh into these factors, which together with the inequitable distribution of major health services, could put additional strain on the mental health of the slum women. Moreover, early marriages, low prevalences of family planning, and early & unwanted pregnancies are common in urban slum women due to inadequate access to health and SRH services [15,24]. Consequently, most early and unintended pregnancies can potentially result in spontaneous abortion. However, the uptake of SRHR and post-abortion care services are notably low in the slums due to high costs and a lack of awareness [25][26][27][28][29]. Additionally, restrictive laws and costly formal care push vulnerable women to perform unsafe abortions. They then fail to use the post-abortion care services [4,30,31]. The available PAC service packages accessible to Bangladeshi slum women comprise emergency treatment for complications and advice regarding family planning [32], but there is no arrangement for any services related to mental healthcare. However, global studies indicated specific mental health support interventions, such as counseling, are beneficial for women after a spontaneous abortion. [33][34][35][36]. Moreover, previous studies stressed the need for integrating psychosocial support services into the PAC package for women who experienced pregnancy loss or abortion [9,34]. The mental health consequences of spontaneous abortion among slum-dwelling women are largely understudied. Also, very few studies have explored the association of factors such as employment, education, wealth index, SRHR knowledge, and utilization of PAC services with the mental health of these women. Therefore, it is essential to explore the mental health issues of women who have experienced spontaneous abortion in poor-resource settings and informal settlements. Furthermore, such evidence is empirical and can guide the relevant policymakers to integrate mental healthcare into PAC services in the future. This study was conducted to estimate the prevalence and possible predictors of anxiety and depression in women with experience of spontaneous abortion living in slum areas in Dhaka, Bangladesh. --- Methods --- Study method and settings This cross-sectional study was conducted among married women living in selected informal urban settlements and communities of Dhaka North and South city corporations and Gazipur city corporation, where the urban health and demographic surveillance system was implemented. The baseline information on the pregnant women was gathered from the urban health and demographic surveillance system , one of the biggest surveillance systems of informal urban settlements in Bangladesh. The surveillance system has been running since 2015, directed by the health system and population studies division of the International Centre for Diarrhoeal Disease Research, Bangladesh . The total five most significant informal settlements -i.e., Mirpur, Korail , Shaympur, Dhalpur , and Tongi were under the surveillance system. The field workers were recruited and trained to gather information quarterly on basic socio-demographic characteristics and events, including pregnancy outcomes for surveillance. The details of the surveillance were reported elsewhere [37]. We included all married women with pregnancy outcomes from July 2020 to December 2021. The baseline information on these pregnant women was gathered from the UHDSS database. Among those, we identified the women who had experienced any form of abortion during the study period and found 361 spontaneous abortions and 169 induced abortions. We consider one and a half years based on the Broen et al. study, which mentions the adverse effects of pregnancy on women's mental health over time. Thereby, we conducted a cross-sectional survey among those women with spontaneous abortions. At the time of the survey, 115 women had migrated from the surveillance areas, since this population is also known as the floating population because of their remarkably high migration rate, which is a result of unstable living conditions and nature of jobs [38]. Furthermore, the field team approached the rest of the 246 women who met the inclusion criteria of having a spontaneous abortion. The final sample size included 240 who agreed to participate . --- Data collection process A semi-structured Bangla questionnaire was developed through an extensive literature review and was later developed into the Java-SQLite software. This digital questionnaire was mounted on Android tablets to be administered by trained UHDSS field workers. These field workers were also trained by the research team to collect sensitive mental health, reproductive healthcare service utilization and abortion-related information from the vulnerable women. The field workers were given lists containing the names and household information of 246 participants extracted from UHDSS data. They tracked the respective participants and approached them for an interview time and place convenient to them. Proper privacy was maintained during the interview by conducting it in the absence of the husbands and other members of the family. All the interviews were conducted at the participants' households as per their preference. The questionnaire had sections on socio-demographic characteristics collected from the UHDSS database, sexual and reproductive health-related knowledge, receiving post-abortion care , and experience of violence. Moreover, the assessment of anxiety and depression was done using two psychometric assessment tools: the General Anxiety Disorder and the Patient Health Questionnaire [15,39]. --- Variables of interest --- Dependent variables The scores of Generalized Anxiety Disorder and Patient Health Questionnaire scales were considered as the dependent variables for this study. --- Generalized anxiety disorder scale Anxiety symptoms among the participants were assessed by the Generalized Anxiety Disorder Scale [34]. The GAD-7 scale consists of seven items, and this scale has been validated and used in Bangladesh in several studies [40,41]. Participants were asked how often they had experienced each symptom during the last two weeks. The response was scored on a four-point Likert scale [34]. The total scale ranges from 0 to 21. The symptom severity scores were 0-4 for minimal, 5-9 for mild, 10-14 for moderate, and 15-21 for severe [23,35]. For the purpose of modeling, GAD-7 was considered into two categories: minimal renamed "no anxiety", and others three groups, "presence of anxiety". In this study, the case of anxiety was considered when women had the mild to severe anxiety category [2][3][4]. The internal consistency of the GAD-7 is reported as excellent with an average inter-item covariance of 0.477. --- Patient health questionnaire Patient Health Questionnaire , which has previously been validated in Bangladesh, was used to evaluate the level of depressive symptoms [42]. It has nine items, each with a four-point Likert scale ranging from 1 to 4 . The total score ranges from 0 to 27. The scores for symptom severity were counted as 0-4 for minimal, 5-9 for mild, 10-14 for moderate, 15-19 for moderately severe, and 20-27 for severe symptoms of depression [43]. Additionally, for the model, PHQ-9 was categorized into two groups, i.e., no depressive symptoms and the presence of depressive symptoms. The minimal category was considered as no depressive symptoms, and the rest of the categories were considered to have depressive symptoms. The case of depression was considered when women's scores in the PHQ-9 included them in the mild to severe depression category [2][3][4][5]. The Cronbach's alpha of the PHQ-9 in the present study was estimated at 0.8628, with average interitem covariance of 0.433. --- Independent variables Socio-demographic variables included age and year of education as continuous variables, household wealth index , and working status . In addition, the history of live birth , stillbirth , and contraceptive use were also included. The principal component analysis was used to calculate the factor score of each variable, and the index was constructed as a weighted sum of these items. The index scores were ordered ascendingly and classified into three categories matching the economic status of the slum population. The women were classified as poorer if they belonged to ≤ 20th quintile, poor if they belonged to the 21st to 79 th, and wealthier if more than the 80th quintile. Having SRHR knowledge, receiving post-abortion care , and experiencing any violence, either physical or verbal , were also considered as explanatory variables for the mental health status of the women. --- Statistical analysis Descriptive analysis , bivariate and logistic regression analyses were performed to assess the correlates of depressive and anxiety symptoms. Heteroscedasticity was tested using the Breuch-Pagan test for heteroscedasticity, and multicollinearity was tested using the variance influence factor at the accepted score 5.00 [44]. A p-value less than 0.05 was considered significant with a 95% CI. All statistical analyses were performed in the STATA windows version 15.0 . --- Results --- Characteristics of the participants The mean age of all participants was 26.12 years, whereas the mean age of women with depressive symptoms and anxiety was 26.27 years and 26.52 years respectively. Participants had, a 4.86 years of schooling and were mostly unemployed in both of the mental health outcomes in general. More than half of the women lived in poor households, followed by the wealthier and poorer quintiles. Approximately, onethird of the women had no live births, used contraceptives, and 12% of the respondants had previous experience of stillbirths at the time of the survey . The majority of women developed depressive symptoms, whereas more than half of the respondents reported to have anxiety following a spontaneous abortion. The distribution of socio-economic and reproductive health-related attributes of the women with depressive symptoms and anxiety is given in Table 1. --- Prevalence of depressive symptoms and anxiety One of every ten women had severe forms of depressive symptoms and anxiety . The prevalence of women with moderate levels of depressive symptoms was higher than that of women with moderate levels of anxiety . One in three women had mild levels of depressive symptoms and anxiety . Additionally, more women experienced depressive symptoms than anxiety after the spontaneous termination of the pregnancy. --- Associated factors of depressive symptoms and anxiety Based on logistic regression, education, SRHR knowledge, and receiving PAC were significantly associated with higher GAD scores . On the other hand, working status, SRHR knowledge, and taking PAC were significantly associated with PHQ scores . With every increasing unit of classes of formal education, there was a 18% reduction in the odds of developing anxiety . Women who received post-abortion care had a 90% lower risk of developing anxiety and depressive symptoms compared to those who did not. On the contrary, the chance of developing depressive symptoms and anxiety was more than 70% higher for the women who has higher knowledge about their SRHR (AOR: 1.72; 95% CI: --- Discussion Spontaneous abortions are known to have long-lasting and severe effects on mothers. A pregnancy loss has been known to cause a lack of self-efficacy, hinder relationships with family members and decrease quality of life [45,46]. However, the studies on these relationships were either conducted in developed countries or focused on the physiological repercussions. Therefore, the psychological consequences of loss of pregnancy in disadvantaged populations in developing countries were lacking. To the best of our knowledge, this paper is the first to evaluate the impact of spontaneous abortion on mental health among the women slum dwellers of Bangladesh. The findings of this study can encourage policies to restructure the existing maternal health care services and improve the well-being of women who belong to the most disadvantaged portion of the population. Our study reported a mild to severe anxiety and depressive symptoms rate of 58.75% and 77.50%, respectively, among the women who had spontaneous abortions. We included the mild category for both mental health conditions as it is regarded as the early stage, and early detection of these difficulties will better ensure the impact of any therapeutic intervention, preventing the onset of complex mental health disorders Fig. 1 Prevalence of anxiety among the slum women with experience of spontaneous abortion Fig. 2 Prevalence of depression among the slum women with experience of spontaneous abortion [47]. The prevalences of depressive symptoms and anxiety are much higher than the prevalences reported in the National Mental Health Survey-2018 of Bangladesh [48]. Moreover, the rate of depressive symptoms in women who experienced spontaneous abortions in our study is higher than that of Sri Lanka, and the level of anxiety is higher than that of Eastern and Southern African countries [49,50]. So, it is crucial to address this greater burden of mental health consequences among slum women, as this can also affect their subsequent pregnancy and compromise the overall fertility span [45,51]. Our findings stated that women from urban slums who received a higher level of education had lower anxiety symptoms. It has been reported that low education in women increases the possibility of accepting misinformation, overestimating risks, and underestimating the benefits of abortion services [52,53]. These misconceptions about the health risks of abortion may exacerbate anxiety among women with lower education about the procedure and affect their ability to cope afterwards [52][53][54][55][56]. In addition, such misperceptions generate negative stereotypes about women who have abortions, contributing to stigma and exaggerating the risks of the abortion procedure [55][56][57]. On the other hand, women with more education are expected to be aware of the safety and consequences of abortion and contraception, making them more resilient and denoting less restrictive abortion beliefs [52]. Moreover, evidence supports that integrating self-care education into prenatal service programs effectively reduces anxiety and depression after a spontaneous abortion [41]. Therefore, ensuring education for women living in slums that incorporates SRHR and mental health components would be crucial to reducing the consequences of an abortion. In addition, a lower depression score through PHQ in slum women was found in those who were employed compared to unemployed women. Past studies also reported that working status could improve physical and mental health outcomes, especially lowering depression among individuals [58]. Financial stability gives women the autonomy to make decisions and enables them to seek healthcare quickly [59]. Moreover, peer support in the workplace increases the opportunity to share inner distress, learn about abortion-related information, and get support from women with similar experiences, which can help reduce mental health complications [60,61]. The low affordability of quality PAC services has been linked to depressive symptoms in slum women [62]. Therefore, promoting women's participation in economic work is crucial, enabling them to exercise the decision-making process and increase their access to need-based healthcare services. [51]. The multivariate analysis reported that increased levels of anxiety and depressive symptoms were associated with having higher SRHR knowledge. Global studies support that the prevalence of spontaneous abortions is independent of the woman's will or even her understanding [63]. Our study findings reported significantly higher scores of GAD-7 and PHQ-9 among the women with a higher level of SRHR knowledge. This might be due to their inability to prevent the event despite having SRHR knowledge. Furthermore, a higher understanding of SRHR does not ensure uptake and compliance with the services by women [63,64]. Hence, the community-based promotion of SRHR services might increase women's reproductive healthcareseeking behavior and utilization of services which will aid in limiting psychological complications [65]. Our study also reported that receiving post-abortion care was significantly associated with lower rates of anxiety and depressive symptoms. As per the evidence, delaying or not receiving post-abortion care might cause inescapable losses, such as physical disability and losing childbearing capacity, leading to further mental health complications [66]. Standard post-abortion care usually comprises quality screening and counseling procedures which can help minimize psychological impacts among women [65,67]. In Bangladesh, formal PAC care services only include support for incomplete abortions and advice regarding family planning with no psychosocial support services [68]. However, evidence supports psychosocial support services combined with appropriate medical consultation can reduce grief and improve women's functioning through proper coping guidance and information about future pregnancies [69,70]. Therefore, further research could explore integrating psychological counseling by training service providers to provide basic psychosocial support and follow-up care in PAC. These could be possible solutions to mitigate the psychological burden among the women who experienced pregnancy loss [69]. In addition, increasing awareness about the availability and importance of accessing PAC services should be ensured to improve the quality of life of the slum women who have had a miscarriage or induced abortion. --- Implications for future practice The findings highlight important considerations for public health policy and the provision of mental health and SRH services for socially disadvantaged women, particularly those who live in urban slums. Recent studies highlight the importance of fulfilling SRHR needs to improve the overall well-being of women. Since poorer mental health outcomes occur among women after a spontaneous abortion, it is critical to enhance existing PAC services by including mental health services such as post-abortion mental health counseling, psychiatric medications, follow-up, and referral for severe psychological risks. Also, it is essential to investigate the women's experiences and healthcare needs following abortion. Moreover, it is necessary to raise communitylevel awareness, reduce stigma and build capacity of local community-level healthcare workers to provide basic psychosocial support, and SRH care for low-income women and adolescents. --- Strengths and Limitations A few limitations should be considered while interpreting the findings. One of the potential limitations was that, as a cross-sectional study, it did not establish any causeand-effect relationships among variables. Future studies assessing anxiety and depressive symptoms among women who did not experience a spontaneous abortion should be conducted to better understand the situation. Moreover, abortion-related data was collected via a retrospective inquiry, which may lead to recall bias and memory lapse. In line with this, the current study explored mental health soon after the event, but the long-term effects and possible demographic predictors should also be investigated. Additionally, this study only included quantitative data; and future studies should be conducted to explore in-depth women's experiences after an abortion. Lastly, the study was conducted on women living in the selected informal settelments of Dhaka city, and the findings are not generalizable to all slums in Bangladesh. Despite the limitations, one of the major strengths of this study was that, to the authors' best knowledge, it is one of the first in Bangladesh to explore the mental health conditions of women with a history of abortion. Additionally, it assessed it in a population of marginalized women largely understudied in research. Moreover, the data were collected from a surveillance system, which followed a scientific approach for tracking the demographic and health outcomes of the slum population, which could be beneficial for designing large-scale studies. Furthermore, as the population is under a surveillance system, monitoring and evaluation of the behavioral change is possible in the future if an intervention is provided by comparing the data. --- Conclusion The present study is one of the first, to the authors' knowledge ever, to explore the association between spontaneous abortions and the mental health conditions of slum dwellers in Dhaka, Bangladesh. It provides evidence that the rates of anxiety and depressive symptoms amongst this vulnerable population are very high and provided an indication as to which factors could be driving them. The findings showed that higher education and employment rates among women are protective against mental health difficulties after an abortion; this highlights the need to ensure that slum dwellers have access to education. In addition, this study also recommends empowering women by improving their participation in economic sectors, paving the way for increased autonomy and decision-making rights. Most importantly, this study showed that accessing PAC services helped prevent mental health distress, and therefore, immediate action is required to integrate mental healthcare into the formal PAC service package while ensuring its availability, accessibility, and affordability in Bangladesh. --- --- Abbreviations --- AOR Adjusted Odds Ration GAD-7 General Anxiety Disorder-7 PHQ-9 Patient Health Questionnaire- --- --- --- --- Competing interests The authors declare that they have no potential conflict of interest in the publication of this research output. • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year --- • At BMC, research is always in progress. --- Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? 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Background Globally, major emphasis has been placed on understanding the physiological consequences of losing a pregnancy. However, its mental health impact on socially disadvantaged women remains unexplored. To further inform the field the present study investigated the prevalence and factors associated with the development of depressive symptoms and anxiety among women with a history of spontaneous abortion living in the urban slums of Dhaka, Bangladesh. Methods Information was obtained from 240 women who experienced a spontaneous abortion from July 2020 to December 2021. It was obtained through the urban health and demographic surveillance system (UHDSS) survey. Generalized Anxiety Disorder (GAD-7) and Patient Health Questionnaire (PHQ-9) were used to measure mental health symptoms. Bivariate and multivariate linear regression analyses were performed to assess the associated factors with the mental health outcomes.Of the 240 women, majority (77.50%) of the women experienced mild to severe depressive symptoms and more than half (58.75%) of the respondants experienced mild to severe anxiety, within one and half years of experiencing spontaneous abortion. A higher level of education and being employed were protective factors for anxiety and depressive symptoms, respectively. However, women with higher sexual and reproductive health rights (SRHR) knowledge had significantly increased anxiety and depressive symptoms. In contrast, receiving post-abortion care (PAC) was associated with decreased anxiety and depressive symptoms.The findings indicate that ensuring access to affordable PAC services and integrating mental health services into the standard PAC service package is crucial. This study also emphasizes the importance of providing education for women living in urban slums and encouraging them to participate in economic activities.

Introduction The family pattern in Nepal is patriarchy, known as families dominated by men only. Regarding this situation, in my opinion, and experience, there are other aspects also which enhance discrimination and domestic violence in Nepalese family systems. Many people have false beliefs about how and why violence against women happens. For us to effectively respond to violence against women, we must confront these myths. Not just physical violence is considered to be violence against women. It covers financial, emotional, psychological, and sexual abuse in addition to other types of abuse. Violence against women refers to any gender-based act that causes or is likely to cause bodily, sexual, or psychological injury or suffering to women, including threats of such acts, coercion, or arbitrarily denying them their freedom, whether it takes place in public or private life. Feminism also has a connection to violence and prejudice against women. Pluckrose & Lindsay have examined the relationship between feminism and gender and found that for well over a century, feminism has been one of the most important social movements in human history, working to improve the lives of slightly over half the planet's population; it has always been divisive and extremely unpopular -possibly not least because of its triumphs; but by the year 2000, however, something in feminism altered. It can be imagined that women got something as freedom in NGOs' and INGOS' documents, but it remained a dream in reality. In the life of women, a significant threat to many women is domestic abuse to learn how to escape a risky situation and recognize the warning signs of an abusive relationship. One of the most pervasive human rights violations in the world, violence against women and girls occurs daily, numerous times, all across the world. It prevents women and girls from participating in society fully and equally because of the severe short-and long-term physical, economic, and psychological effects it has on them. There are no words to describe how much of an influence it has on people's lives, families, and society at large. The following feminisms have also been highlighted by Pluckrose & Lindsay intersectional feminism, radical feminism, materialist feminism, and liberal feminism. They further added that during the "second wave," which took place between the late 1960s and the mid-1980s, liberal feminism was the most broadly based activist movement; similarly, the two prominent scholarly streams of feminism at this time were radical and materialist feminisms, which are somewhat overlapping and rival. From the middle of the 1990s on, intersectional feminism has supplanted the previous varieties in academic and activist circles; in the new millennium, intersectional feminism is firmly in control, and it is this perspective that has led to the tremendous change just mentioned. The abovementioned analysis is a theoretical perspective regarding gender and violence. The following is an excerpt from Pluckrose & Lindsay argument that the three primary feminisms in the 1960s were radical, materialist, and liberal. Progressively extending to women all the liberties and rights of a liberal society is the goal of liberal feminism. Materialist feminists were worried about how capitalism and patriarchy collectively limit women, particularly in settings like the workplace and the family. Radical feminists emphasized the patriarchal system and saw men and women as oppressed and oppressor classes, respectively. They were revolutionaries who sought to transform society, and destroy the idea of gender , as well as capitalism and patriarchy. They have further added that the most crucial thing to realize is that, while the liberal feminist approach had the most support from the general public, radical and materialist feminism predominated in the academic, especially from the 1970s onward. The above-mentioned text has shown that women need freedom for their identity. On the other hand, Liberal feminism is in favor of women but materialism and radical are in favor of keeping women under the control of male patriarchy under the two frames of oppressed and oppressor. Postmodern inter sectionalism has mostly supplanted other types of feminists as well, such as radical and materialist ones. Postmodern feminists also outnumbered liberal feminists, who have historically been more active in political activism than academic research. Liberal feminism has been the clear, primary target of post-modernists because it adheres to modernist values of secular, liberal democracy, and individual agency within the context of universal human rights. Similarly, women in Nepal have been living under high pressure of discrimination and domestic violence. Mostly, the victims are daughter-in-law, wife, and also girl child in a family. In many families, women have to live outside of the family's mainstream. Although some women have got freedom, they have extreme freedom in such a way that other women in the world have not got such type of freedom. On the other hand, most women are in such a situation that their human rights have been violated in such a way that they cannot be found in another world, I think. Any act of gender-based violence that causes physical, sexual, or emotional pain or suffering to women and girls is known as violence against women and girls. This includes threats of such actions, coercion, and arbitrary deprivation of liberty, whether they take place in public or private life. The term "violence against women and girls" refers to a variety of crimes, including but not limited to physical, sexual, and psychological assaults committed against women and girls within the home or in the larger community and those crimes that the government either supports or condones. --- Objective The objective of this study is to show some examples of the nature of domestic violence against women in Nepalese families and societies. --- Research Questions The research questions framed for this study are: 1. What types of domestic violence do women face in Nepalese families? 2. What are the reasons for torturing women in Nepalese families? 3. How will it be possible to stop domestic violence against women in Nepalese families? --- Methodology The methodology of this study is qualitative. The data collection process was purposive including snowball sampling with five women who were from different parts of Nepal and they were living in Kathmandu, Nepal. The women had experienced domestic violence made on them as well as had got true experiences of domestic outbreaks of violence made on others in their locality and relatives. To collect data, some girl students studying Social Work subjects were used so that the women could tell their stories without any hesitation. The data collecting tool was an open-ended interview and the technique of analysis was description and interpretation using language but no quantitative technique was used. A narrative approach is used to conduct this study. This study fulfills the gaps of the extreme nature of domestic violence made on women in the family, which was not exposed previously through other research. --- Literature Review The literature review made for this study is on domestic violence, discrimination of women, exclusion of women in families, and feminism theory. --- Domestic Violence It is generally known that women have been subject to domestic violence in Nepalese families. It may be the same in other countries and families. Women are found to have been tortured, burned to death alive, asked for dowry from their parents, and taken as not human beings by their married families. Regarding domestic violence, Hilder & Bettinson, referred to the moral and legal responsibility to address domestic violence and abuse as a matter of current worldwide concern. This view shows that domestic violence against women is experienced in every country in the world. Regarding this concern, civil society has also been found to have remained outside the gate of the entrance of domestic violence. Similarly, in light of the current circumstance, the Council of Europe has noted that at a regional level, the Council of Europe Convention on Preventing and Combating Violence against Women and Domestic Violence Council of Europe provides legally binding standards to enhance the prevention of violence, the protection of victims, and the prosecution of perpetrators through a set of integrated policies, calling for stronger coordination of legal and community-based response. Although different organizations make rules and regulations to stop domestic violence against women, it has not been much more successful. Furthermore, according to McQuigg, , a prevalent reluctance to regard the conduct of such behaviors as a fundamental violation of a person's human rights is maybe one of the intrinsic weaknesses of societies in effectively addressing the issue of domestic violence; domestic abuse evidently violates a person's right to life, as well as their freedom from torture and other cruel or inhumane treatment, as well as their right to respect for their private and family lives. As mentioned above, however, it hasn't been until recently found that domestic violence has been acknowledged as a problem covered by human rights law. Although we talk of different organizations concerning the enhancement of women, they are on paper but not in the real world. The degree of complexity tends to rapidly rise when it comes to understanding domestic violence, according to Ross, , who claims that humans are the most complex species on the planet; also, domestic violence has been the subject of several theoretical explanations that have developed over the years. As mentioned here, these explanations offer fresh perspectives on actions that are seen to be exceptionally terrible and cruel. Sociological explanations of the causes of domestic violence have received more recognition among academics from many intellectual traditions despite their divergent views. In Nepalese families also, violations against women are highly increasing despite a modern system of family. --- Discrimination of Women From the very time of birth, girl children are discriminated against in their beginning family. It is known that sons and daughters are treated differently. Regarding women, Haralambos & Holborn have stated that women are generally underrepresented in high-prestige jobs and positions of power, although females have children, and are mothers, spouses, and caregivers for all home tasks. Similarly, women everywhere feel discrimination; in families, girl children are provided cheaper clothes than sons/boys; daughters are sent to cheap schools but sons are sent to costly schools. Ways of dealings are also different for a son and a daughter. As a whole, women are devaluated in family and community. Ortner, referred to this circumstance by stating that culture is valued more highly in every community than nature. Man's ability to govern and regulate nature is mediated through culture. The fundamental justification for the undervaluation of women is the widespread belief that culture is superior to nature. Women are thought to be less superior to males since they are perceived as being closer to nature. Ortner, argument is supportive of the present situation. The husband and his family relatives beat her and abuse highly thinking that she has not got any credit. Although this view was framed long ago, it seems as relevant today as it was in the past. In Nepalese families, women have been looked at in a very narrow background. Furthermore, a daughter-in-law has no any credit in many families. Regarding this situation, Rao has stated that men and women have never been treated equally or given the same statuses throughout the history of the human race. Despite their desire for equality, women have not been able to live lives exactly on par with men but women face inequality, discrimination, and exploitation everywhere. As mentioned by Rao, the gender role in India and Nepal is the same because of cultural similarities. On the other hand, Swami Vivekananda has mentioned that in any community, the kind of status given to women reflects the nature of that country's cultural diversity and the degree to which its civilizational ideals have been attained; also, neither can the nation or the country that does not appreciate women ever rise to greatness Rao . The view of Swami Vivekananda is highly acceptable. As we say human beings, it composed of both men and women so keeping women back, progress is not possible. --- Theoretical Review Theory helps to build the direction of a person's opinion about what works and how it is done. In this way, the theory applied to this study is gender inequality. Regarding this situation, Ritzer has stated that men and women are situated in society differently and unequally; women, in particular, receive fewer material resources, social status, power, and opportunities for self-actualization than do men who share their social location; furthermore, this inequality is caused by the way society is set up, but not by biological differences between men and women. Liberal feminism: Similarly to the feminist theory, this study adheres to liberal feminism. According to Ritzer liberal feminism is the main manifestation of gender inequality theory; it asserts that women can make a case for equality with men based on a fundamental human ability for reasoned moral agency and that sexism and patriarchy are the root causes of gender inequality in the workplace. As mentioned above, liberal feminism, which asserts that women's inferior standing in society is based on uneven opportunities and isolation from males, is one of the first versions of feminism, as was previously established. This corpus of feminism, which sprang from the abolitionist and women's movements in every nation, is concerned with eradicating gender inequity. --- Data Presentation and Discussion To collect data about domestic violence and discrimination, five women were selected and they were interviewed. Their pseudo names are mentioned here. Some girl students were managed to interview them. The pseudo names of the participants are -Goma, Harikala, Janaki, Dil Kumari, and Astha. Regarding domestic violence experienced by Goma said that she had been married to a very cruel Brahmin caste person. If she had known the person was so cruel, she would not get married to him. Her marriage was arranged marriage. There was a widow sister of her husband in the family. She always put the blame on her before her husband; and immediately, her husband would become fire with anger and used to beat her using whatever things were handy for him. He used a fist and stick to beat her. Once, after many years of torture like this, she thought it would be better to die rather than to live and be alive; thinking so, she picked up a strong rope and went to a forest to hang up and die rather than be alive with such torturous life; but some other people knew about it and stopped her from hanging and die; the people brought her home and her husband was so much afraid that he left home and did not return for some years. The reason for the domestic violence against her was his husband's sister and also her mother-in-law. Harikala had also the same type of domestic violence in her family. Her husband was also very rude and always looked down on her with his male superiority. True patriarchal power was visible in her family. She was almost daily beaten and given mental torture by her husband. She always lived in extreme terror and fear until the death of her husband. She rather told that she was not worried about her husband's death. It was because of the torture given to her by her husband. Janaki reminded her sister's story and added to her story that her sister's husband was also very cruel and dangerous. According to her story, when her sister's husband had time to take food, she had to give fodder to the cattle, and the cattle had to finish eating fodder by the time he would finish eating food; and, otherwise, if the cattle would not finish eating fodder, he would beat her very harshly and dangerously. At last, she thought it difficult to stay there and left the house and family along with a son. The son was separated from her. After a few years, she died but her husband and son were alive. It was also heard that the father became harsh with his son, too. Dil Kumari also added to her story that she got married to an educated person who had not got so much property. He had got only a mother in the family. But Dil Kumari had not known that a widow can be so much dangerous. It means that her mother-in-law was very active in the matter of domestic violence, and could not see her daughter-in-law with her eyes; she dominated her daughter-in-law-from the very time of the day of marriage; but the marriage was arranged marriage. She forced her son to abandon Dil Kumari and the reason was that Dil Kumari had not got a dowry from her parents. But her husband being an educated person and without greed for property, he could not accept his mother's force being put on him to leave his wife forever and get married to another woman. She further added that her mother-in-law managed to feed a herbal medicine with the help of a witch doctor which could stop the birth of a child so that she would be barren all her life, but she was clever and did not eat the medicine, but also the effect of touching the medicine with magic chanting of the witch doctoraffected her, and she had to take help of another witch doctor and herbalist to return her condition to give birth to a child, and now she has got a son and a daughter; they are grown up and her daughter is now married and her son has completed higher education in an Engineering program. According to her story, when her mother-in-law could not convince her son to leave her , she stayed alone to blame both her son and daughter-in-law. Now Dil Kumari's motherin-law is dead and she remembers the harsh situation got from her mother-in-law. But her husband was a polite and educated person so he did not follow domestic violence as forced by his mother. Astha also told a serious story about her husband that he always used to beat her in the small matter, but her sons took favor of her and he was made a bit under control. But when he died, she says, she got some relief. Now she does not even remember him because of his habit of giving torture to her. --- Findings The above-explained data show that domestic violence is often made to the daughter-in-law and wife. This is male dominant family supported by the husband's family members, and a married woman's mother-in-law becomes jealous of her daughter-in-law thinking of her as a piece of metal object and a piece of wood, an object. In such a situation, domestic violence takes the highest strength so a married woman goes for suicide. An important finding of this study is that if a motherin-law -becomes friendly with her daughter-inlaw, all types of domestic violence can be taken into control; this is the point of a gap this research tries to fulfill; it is because, only sons and daughter-in-laws -have been on the blame because of disciplinary barriers; civil society also does not take favor of a daughter-in-law and her innocent behavior. In this way, a family becomes hell due to the high level of domination made on a daughterin-law and a wife in the family. The main reasons for domestic violence are the greed for money to obtain from the wife's parents with the support of a husband's family members. --- Conclusion In terms of domestic violence, it can be said that an innocent girl gets into a deep hole of hell which is very difficult to cross and jump out of as well. In our community, civil society also does not make convinced people that a girl brought into a family through the process of marriage is also a human being and should be treated as a human being, but not like an iron nail. If a married girl's mother-inlaw supports her, the husband also does not dominate her. But thinking of a girl in her husband's family as good as possible is a nightmare dream so I have mentioned this situation as an unsolved responsibility. It means that events are taking place but no society goes to solve it in favor of the victims of the event, but members of the community burn a fire for such a situation.

The purpose of this study is to present domestic violence existing against women in Nepalese families and societies. Although people are educated, domestic violence against women is not minimized and appears in many families as before. This research study also shows that patriarchal families and societies are extremely dominating women. Design/Methodology/Approach: Furthermore, regarding methodology, this is a qualitative study, and data are collected through interviews and document analysis. This is an ethnographic design under qualitative study. The study maintains convenience sampling under purposive sampling related to a qualitative study. A woman fallen victim to domestic violence will be identified and interviewed and through her another woman of a similar category is identified to interview and collect data. Findings: Nepal is a small country situated between two large countries, China and India. Nepal is surrounded by China in the northern part and by India in the eastern, southern, and western parts. So, the lifestyle of the people in the northern part of Nepal is like that of the Tibetan tribes; and similarly, the lifestyle of the people in the eastern, southern, and western parts is similar to that of Indian people. The findings of this study show that society has not taken responsibility to control discrimination and domestic violence taking place against women. This is an unsolved social responsibility. Research Limitation: This research study is ethnography in research design that does not cover more aspects of the male population. And also it is a qualitative study and does not point out any statistical tools and numerical data. Managerial Implications: This research implies that women need equality in family and society, maintaining a humanistic view of women and implications for further research. Originality/Value: This research study has maintained its originality and it has also got great value. The delimitation of this study is that it concerns the discrimination and domestic violence against women in families and societies.

Introduction With the arrival of information age, a large amount of information is flooding our city life, and the digital form of social innovation has appeared. Digital social innovation has become a hotspot for policy-makers, entrepreneurs, researchers, and start-ups. It presents us with a brand new vision. Previous research like NESTA's research on DSI [1] has pioneered the field of DSI from both research questions and methods, and created many cases that laid the foundation for our research. Nowadays, for academic institutions like Parsons DESIS Lab [2], DSI has become their new thematic group, and its work provided the theoretical basis for our study and reference. Their focus on digital technologies and platforms are considered as the organization tool for connecting community to individuals. Based on the assumptions of the previous research, we believe that digital technology is a dominant and pivotal new way to support people, customers and communities to collaborate and co-create a wide range of social needs. Consisting of a group of DESIS laboratories and partners, DSI group is currently exploring a different approach, focusing on the literal aspect of digital technology which is more technical and academic. The purpose is to investigate not only the cases and trends in social innovation, but also the corresponding design research issues and strategies in the digital, social and ubiquitous network context. From the perspective of design, the definition and features of DSI need to be concerned. What is more important is how to apply DSI to real social practice scenarios in a standardized and process-oriented way. In order to make the project closer to reality, we worked with NGOs, charities and social enterprises to develop interdisciplinary cooperation among governments, organizations and research institutions to find new possibilities during the exploration process, Also, following the trend of globalization, we actively cooperated with Urban Studies Program at Stanford University, and formed cross-regional, cross-cultural, and interdisciplinary teams to test and practice DSI. We found that urban design is not only about physical infrastructure, but it is also about the services and amenities where infrastructure inhabits. In addition, we use four pillars of sustainability -social equity, environmental quality, cultural continuity, and economic vitality, as the framework to guide the direction of the project [3]. The four pillars have significant referential meaning to the summarized features and evaluation standard of DSI. --- Society Background According to our previous research [4], the initial prototype of the city is formed by aggregation of population and commodity exchange. A real sense of a city is to make its citizens live well with support of urban infrastructure and energy, food, water, transportation, recreation and finance system etc. The intervention of new ICT technology changes the built environment to a sensible, interactive and transferred place where support human activities in all levels, and make the city's physical space and intangible networks merge together to form a very complex ecosystem. In the current state, the smart city is envisioned as wired and ICT-driven cities that provide better urban life [5], innovative services [6], new business opportunities [7], efficient governance and sustainable environment development [8]. More and more cities are beginning to consider civic participation, and regard the smart citizen as a new direction of smart city. Currently, governments around the world are taking actions to cooperate with their citizens in the process of designing and constructing smart cities, based on their specific situations and objectives. Social media is being widely used as a way to get citizens involved. Participatory sensing, which is empowered by the development of ICT, is also a significant approach to collecting data from citizens. Some government municipalities also launched urban sensing applications, such as the NYC 311 service [9]. New York City held its annual city hackathon 2013 with the theme of "Reinvent Green", aiming to help build digital tools and applications to support New York in leading greener lives [10]. From public benefit to social innovation, companies increasingly turn to CSR3.0 [11]. They will focus on a more sustainable model and revolutionize our understanding on concepts such as product, consumption, wealth and inventions with new methods, ideas and technologies, for instance, in the Intel Core World Social Innovation Week [12]. --- Technology Background Digital technologies and the Internet play an increasingly important role in how social innovation happens. Today's urban development is gradually turning to smart city. New technologies such as the Internet, big data, cloud computing, wearable devices, intelligent home, artificial intelligence and SNS have been applied to social innovation [13], and extend the width and breadth of social innovation from the aspects of the process, performance and content, increasing its efficiency and reducing its complexity significantly. The growth and development of social computing has greatly increased the complexity of the system. On the other hand, coping with complexity also brings new solutions to social innovation. Collective intelligence harvested from relationships among designers, users and organizations, and collective wisdom that acquired from things on Internet can generate greater value from the interaction between people and things. Eventually, innovative, hopeful and sustainable lifestyle can be created [14,15]. --- Research Questions We hope to offer a set of methods to contribute to DSI research in the urban context, and meanwhile to practice it and cooperate with the society from all walks of life. In the practice, we will offer insights and tools from the angle of schools. What is the Main Participant of DSI? In recent decades, many philanthropic and charitable organizations have often turned to non-profit, especially non-governmental organizations , to address some of the world's most intractable social problems. With the rise of those groups, the number of similar social organizations increases. However, their projects and solutions are almost homogenous, and they are also lacking in new theories or thoughts. By carefully re-tooling these organizations with the latest technology and guiding them with the best innovation practices at our disposal today, we can start fresh with a re-booted version of traditional non-governmental organizations: NGO 2.0 [16,17]. What is the Method of DSI? With the goal of social innovation, we focus on the reflection of culture and social value on the aspects of research methods and design tools. Focusing on research questions from the community level, the more mature mode is the Bottom of the Pyramid [18]. In the design field, collective action toolkit developed by Frog Design Company [19], HCD Toolkit developed by IDEO [20] and the DIY innovation toolkit produced by NESTA [21] are all tools for inspiring and supporting social innovation. --- Methodology Our train of thought is: first analyzing the real cases; second concluding the features of them when referring to designing process; then forming the framework of DSI suited to city sustainable background; at last testing our conclusion by practicing. During the process, we used case study and grounded theory as our method and tool. Case Study. According to Thomas [22], "case studies are analyses of persons, events, decisions periods, projects, policies, institutions, or other systems that are studied holistically by one or more method. The case that is the subject of the inquiry will be an instance of a class of phenomena that provides an analytical framean objectwithin which the study is conducted and which the case illuminates and explicates." We studied many DSI cases in order to find a vision for the common features of DSI. Grounded Theory. It's a systematic methodology in the social sciences involving the construction of theory through the analysis of data [23]. From our case studies, we also collected many data. After having done the statistical analysis, we conclude the statistical meaning of these data and deduce the general framework for DSI. --- Contribution. This paper focuses on researching and practicing DSI in the urban context and makes following contributions: • Define DSI in the urban context. • Summarize and conclude the features and framework of DSI. • Support the relative research. • Support innovation teams to take part in DSI practices in the urban context. --- Related Research --- Social Innovation There is a possible future in which services are explicitly designed to tackle social challenges such as climate change and unemployment. Social innovation is now embraced around the world as legitimate public policy in both economic and social arenas. According to the Open Book of Social Innovation [24], the three most significant problems of social innovation are intractable social problems, rising costs and paradigm. There is a growing interest in social innovation among policymakers, foundations, researchers and academic institutions around the world. Despite this interest, there are no a shared or common definition of social innovation. Currently, there are a large number of different definitions in circulation. Goldenberg defined social innovation as the development and application of new or improved activities, initiatives, services, processes, or products designed to address social and economic challenges faced by individuals and communities [25]. In 2003, Stanford had defined social innovation as "the process of inventing, securing support for, and implementing novel solutions to social needs and problems". Five years later, Stanford redefined and broadened the term. The latest approach involves "dissolving boundaries and brokering a dialogue between the public, private, and nonprofit sectors". The current Stanford definition of social innovation is "a novel solution to a social problem that is more effective, efficient, sustainable, or just than existing solutions and for which the value created accrues primarily to society as a whole rather than private individuals." It describes that, "a social innovation can be a product, production process, or technology , but it can also be a principle, an idea, a piece of legislation, a social movement, an intervention, or some combination of them" [26]. Some define social innovation as a type of innovation more broadly. Timo Hämäläinen outlines five types of innovation: technological, economic, regulative, normative and cultural [27]. According to a report of TEPSIE, it defines social innovation as "new solutions , which simultaneously meet a social need and lead to new or improved capabilities, relationships and better use of assets and resources" [28]. TEPSIE found the eight common features of social innovation, which are cross-sectorial, open and collaborative, grassroots and bottom-up, pro-sumption and co-production, mutualism, creates new roles and relationships, better use of assets and resources, and develops assets and capabilities [28]. Robin Murray, Julie Caulier-Grice and Geoff Mulgan from the Young Foundation had identified six stages of social innovation from inception to impact. The six stages are [24]: prompts, inspirations and diagnoses, proposals and ideas, prototyping and pilots, sustaining, scaling and diffusion, and systemic change. In the book, they explored each of the stages in depth, and listed some of the main methods used for each one. --- Case Study Grounded theory believes that a theoretical framework can only gradually be formed through in-depth analysis of data. Therefore, we selected five typical DSI cases in the urban context, Yibo [29], Coca-Cola Hello Happiness [30], Pugedon [31], Yitu [32] and FixMyCity [33], as our primary data to analyze. Yibo provides a novel solution to add advertisements on the Internet. It collects "404 not found" web pages that provide the advertisement service to social organizations. Now, over 200,000 websites have joined in Yibo to provide noncommercial advertisement. The advantage is that it spreads noncommercial advertisements online by fully using resources of Internet. The whole procedure can be easily recorded and traced. Pugedon is a well-designed recycling machine. It feeds stray animals when it receives plastic bottles. At the same time, Pugedon recycles plastic materials for environment protection. On the other hand, it provides a solution to feeding stray animals. By combining these two features, Pugedon motivates people to protect environment and meanwhile care for animals. "Hello Happiness" is a new video from Coca-Cola. In March 2014, Coke installed five special phone booths that accepted Coca-Cola bottle caps instead of coins in Dubai labor camps. In exchange for a 54-cent Coke bottle cap, migrant workers could make a three-minute international call [30]. Similar with Pugedon, Coca-Cola Hello Happiness project is totallyan offline solution. It modifies the traditional telephone booth by replacing the coins with Coke bottle caps. Apparently, Coca-Cola's innovative solution created a positive impact on the society, especially to migrant workers. Yitu provides a multiple-field and map-based solution targeting different social problems such as environment, society and disaster. It is the first multiple-layers social map on which every person can upload and search for different social problems and requirements. Social organizations can generate corresponding social service maps based on the Yitu platform. The maps can be imbedded into the web pages to reduce the cost of development. FixMyCity is a framework for easily building and deploying citizen reporting platforms. Based on web technologies, it enables citizens to report local issues to the responsible local authorities. Through the combination of FixMyCity platform features, bidirectional channels are created between citizens on the one side and local governments on the other. FixMyCity focuses on the extensive support to end-user mobile cross-device and the tight integration of Social Media [33]. During the research of these five DSI cases, we collected keywords in related works, such as project introductions, news and research papers, and summarized the feature descriptions as shown in table. Based on the 5W2H theory, a method in Grounded Theory for microanalysis, which is what, when, where, who, why, how, how much, we selected seven corresponding aspects -deliverable, generation, service model, object, orientation, approach, and operation to categorize the features. We learned from other cases that the content of DSI could also be open data offered by the government or relevant departments and organizations. --- Digital Social Innovation 3.1 Definition DSI is the best solution to city life problems in the era of information. Science and technology have provided guarantees for many unimaginable and undoable things, making efficient and large-scale innovations possible. Today, at a time when urban lifestyle is so fast, science and technology has become more and more essential as a tool of assisting social innovation. DSI is one kind of social innovation that is based on Internet or uses digital ways. Its purposes are to improve the life quality of different groups and help raise different solutions to the same problems in digital way. NESTA had defined DSI as "a type of social and collaborative innovation in which innovators, users and communities collaborate using digital technologies to co-create knowledge and solutions for a wide range of social needs and at a scale that was unimaginable before the rise of the Internet" [34]. In a report of NESTA [13] We define DSI in the urban context as a type of social innovation in which all of the society members get involved both physically and digitally through using digital technologies to co-create and co-design our neighborhood. --- Features We have concluded seven features of DSI through research and practice. They are from the seven aspects shown in Table 1. The seven features corresponding with the seven aspects come out in pairs, complement and reinforce each other. According to Grounded Theory, the features are the substantive theory that we get from the primary data. Through practicing and validating, they gained great guidance to classify the researches on DSI. Platform/Product. Solutions can self-generate or be improved by users on the platform and are open to many other users. A product is effective, professional, complete and validated. Usually, due to unprofessional quality or financial problems, a product comes out at the situation in which users cannot inefficiently find the solution. Original/Reformed. Science and technology has changed our behaviors. An exited and effective social innovation will become a new DSI after digitally reformed. The development of technology has broadened our horizon and motivated social innovation. Whether social innovation is supported by a completely new technology or a combination of existing technologies, it's all original DSI. Online/Offline. The application of Internet can be seen in almost every case of DSI. Online means state of connectivity. Offline means real activities or events. The offline part shortens the distance between innovation result and real life, while the online part provides chances for creating new business models and solutions. Collective/Individual. Collective intelligence helps us solve complex human problems. Crowdsourcing and crowdfunding have already been new modes of generating and incubating innovation. "Collective" means the DSI is executed by the whole society, such as crowdsourcing and crowdfunding. While "Individual" means the DSI is initiated or executed by one person. Result/Process. Results-oriented DSI emphasizes the final outputa solution or a product. While process-DSI emphasizes the middle output. It can be data or social network between the participants generated or established in the DSI process. Open/Customized. Open indicates transparent data, self-generation, low threshold and broad audience. While customized stands for DSIs that have special requirements, targeted audiences, and experts. Light/Heavy. Light operation means less or none cost and manpower resources, using freely, and operating simply. Heavy operation means complex development and maintenance. --- Design Framework Based on the SET factors [35], which are social, economic, and technology, we categorize the features. Then we get the formal theory, a standard DSI design framework, as the guide of our practice to evaluate the sustainability, economic benefits, and efficiency during the process of studying and practicing DSI cases. We summarize them as four evaluation indexes in our DSI design framework based on what we have learned from Tim Brown's Design Thinking [36]. The four evaluations indexes are desirability, viability and sustainability, and feasibility . From the perspective of DSI, social desirability is about building the participatory, vibrant community to support the humanized innovation. Social and economic sustainability means it's an inclusive ecosystem that can create sustaining social values. Economic viability means aggregating the physical and digital resources to build the collaborative platform. Technology feasibility means it's an open, flexible framework based on the new technologies, such as social media, big data, and crowdsourcing. In conclusion, the four indexes of DSI are participatory community, inclusive ecosystem, collaborative platform, and open framework. --- Project Practices To explore the opportunities and services for social innovation and sustainable design patterns in the urban context, we cooperate with NGOs and public institutions to help the students to build a better concept of society problems and find the real demand, and in the same time, we apply our framework for generating solutions. There are 3 examples from the class below. --- Case1: Urban Walkability and Walking Experience. Urban walkability is a problem concentrated on sustainability of future cities from a macro perspective, and it can determine the citizens' life quality and living cost . Case2: Open Air Quality Platform for Government. The haze and smog can directly damage human respiratory system. On one hand, limiting the airborne pollution is an important aspect; on the other hand, the communication among government, enterprises and public has a significant meaning . Youth hostel is a microcosm of society, which has a close relationship with youth's attitude and manner toward life. It also includes many elements: travel, making friends and accommodation . During our study and practice, we did a lot of research on existing related methods and tools that have already been used and practiced thousands of times. By combining and recreating them, we make our own DSI methods and tools for college students in our courses. In order to validate them in real urban context, we conducted some projects together with NGOs and other society organizations. As shown above, our projects have standardized process and completed result. Because of our expertise, our results are drawn mostly from design concern. After this, we still have other valuable things to do: • Firstly, build a DSI sharing platform for the organizations and companies who are planning to do DSI. The platform will contain large quantities of DSI cases and related data, which will be quite helpful for those organizations and companies especially startups. Of course there will be a committee to supervise the platform and keep it working by certain rules. If some groups profit from the platform, in return, they will share their cases and data on the platform. • Although DSI has the social attributes, we can concern the micro aspect of the whole DSI processthe innovation groups. How to make the group more efficient and more creative is the key point. We need to discover what tools, platforms or specialties influence DSI results and how they influence. --- Conclusions Starting with the definition of DSI, we used case study to conclude the features of DSI, and on the basis of these features we developed the DSI's framework used on urban context. Referring to the course practices cooperated with Stanford, we practice and confirm the relevant method, and so that we believe the conclusion have the guiding significance. We will continue perfecting and verifying our conclusion and pay attention on development and promotion of creativity of innovation participant. Also, we will develop more distinctive products and services for society.

This paper focuses on the research and practice of digital social innovation (DSI). The rapid progress in the era of information provides many possibilities for social innovation. At the meanwhile, the development of science and technology has significantly boosted the breadth, depth and efficiency of social innovation. Through years' of research and practice, we improve the definition and conclude the features of DSI from a large number of case studies. Then, by combining the SET factors, we develop the general standard framework for DSI. At last, we use and confirm the righteous and effectiveness of this instruction in practice.

Introduction In recent years, social media platforms have become the main channel for people to share and obtain information. XiaoHongShu, as an emerging social media platform, provides a channel for spreading discourse. In the context of the new era, the concept of equality between men and women in China has gained a kind of legitimacy, and the concept of gender equality in society has continued to advance and develop, which has laid the foundation for feminism's development. As of June 2022, the size of China's Internet users has reached 1.051 billion , of which 51.4% are male and 48.6% are female, which is basically consistent with the ratio of men and women in the overall population, and to some extent verifies that there is no obvious bias or restriction on Internet use by people of different genders. Internationally, scholars have delved into research investigating a variety of social media practices of feminism, including feminist blogs [1], popular feminist hashtags [2][3][4], and the use of social networking platforms such as WhatsApp, Instagram, YouTube and Tumblr to convey feminist messages, images, and identities [5,6], and how the discussions affect feminist-related movement like #metoo [7,8]. In China, more and more scholars have also begun to look at the media practices and roles of feminist discourse in the new media landscape. Some studies have shown that feminist discourse discussions on media platforms can influence the thoughts and behaviours of media users, e.g. the attention, attitudes and discussion of feminist online discourse actions among female college student groups have a positive effect on the willingness to "speak out" [9] . Besides, research on women's topics based on the Xiaohongshu platform has also begun to appear, such as feminism research [10], women's media image research [11], women's image construction [12] and self-presentation [13], and female body image anxiety phenomenon [14] and female identity [15] . Previous research has focused on the role of online feminist discourses on young women's groups. Dai found that female university students' attention, attitudes and discussion of feminist online discursive actions had a positive effect on willingness to speak out [9]. Nevertheless, there is a lack of research on how online feminist discourse influences audience behaviour offline. Besides, in a study by analysing data on girls' participation in feminist activism on social media like Twitter, Facebook, and Tumblr in the United States, Canada, and the United Kingdom, found that girls' strategic choices shape the types of feminism seen on various social media platforms, these distinctive discourses may be related to the platforms' language, culture and social interaction styles , the findings raise the need for further attention to be paid to whether the expression and shaping of feminist sentiment on social media platforms is influenced by specific platform structures and characteristics [6]. Feminism is often used as an important framework for exploring issues such as gender equality, women's rights, diversity of female roles, and empowerment in the film industry in existing research. In recent years, the Barbie brand has gradually introduced some storylines related to women's rights and diversity. The Barbie movie attempts to reflect on traditional gender roles and stereotypes. By portraying female characters as ambitious, intelligent, and versatile, movies can help eliminate stereotypes about women and encourage girls to pursue various interests and professions. However, the "Barbie" movie has also sparked some controversy, and many feminists have criticized the "Barbie" movie and related toys, believing that their appearance standards, body proportions, and other factors still strengthen the unhealthy body image to a certain extent, thereby affecting women's self-esteem and image confidence. Currently, academic discussions about the movie are mostly focused on the economic and educational fields, In the field of mass communication, it is still in an "absent" state. At present, the academic research on new media platforms mainly focuses on such platforms as Facebook, Twitter, Instagram, Weibo, Tiktok, while the research on the media presentation and discourse communication of XiaoHongShu is relatively scarce. However, it is against this backdrop that XiaoHongShu, as a vibrant social media platform, has gradually emerged among Chinese users in recent years. There is currently a lack of in-depth exploration of the platform's communication effectiveness and audience resonance. In the past, research only focused on the image of female media and the analysis of female user behavior, there was a lack of in-depth analysis of male users, as well as a survey of female offline behavior and its impact on feminism in society. The research significance of exploring the XiaoHongShu platform cannot be underestimated, especially in terms of media practice, this study lies in filling the academic gap in the dissemination of feminist discourse on the Xiaohongshu platform. Based on the mentioned research background, innovative points, and previous practical support, the researcher aims to conduct an in-depth research on the dissemination of feminist discourse and public resonance of the Barbie movie on the XiaoHongShu platform, to reveal the association between the movie and feminist views, to analyze the dissemination mode and expression of views of the discourse, to parse the public's emotional attitudes, and ultimately to reveal the impact of these discourses on the development of feminist discourse in society. Given the xiaohongshu's significance for highlighting the pervasiveness of feminism, this study aims to answer the following research questions: 1. How socially engaged is the feminist conversation about the Barbie movie on the XiaoHongShu? What are the main topics and keywords in the posts that relate to feminism? 2. What contexts and emotional colors are used by posters on xiaohongshu when discussing feminist topics? Are the emotions expressed positive, negative or neutral? 3. What are the attitudes and emotions of the audience towards these feminist topics? Are these related to the audience's personal background? 4. Will the audience change their behaviors or thoughts in real life as a result of engaging in discussions on feminist topics on XiaoHongShu? --- Methodology Based on the nature of the platform and sample categories to be studied in this article, a combination of manual and software assistance will be used to collect and analyze samples. --- Data collection This paper collected the posts and their comments related to the feminist topics under #Barbie#, #BarbieMovie# in XiaoHongShu . The data set for content analysis is from the Bazhuayu website , Wenjuanxin is used to collect questionnaires from XiaoHongShu or WeChat users. 133 posts and 9337 first-level comments in XiaoHongShu are collected from 21 July 2023 to 4 August 2023 , Needed to be stated, the data were manually cleaned to remove the invalid micro blogs with tags only, deleted original texts and repeated postings in order to ensure the quality of the data. A total of 226 questionnaires with 0.917 Cronbach alpha coefficient are distributed from 23 August 2023 to 30 August 2023 after remove invalid samples . Besides, the researcher conduct semistructured interviews, involved obtaining information from 5 XiaoHongShu users whose posts are hot, in order to gain insight into XiaoHongShu's users' attitudes towards the development of feminism in Barbie film. --- Data Analysis Data analysis involves three stages. In the first phase, text mining is performed to determine the semantic insights of the posts and comments, and the feminism-related topics are categorized to help us do further research. In the second stage, sentiment analyses are used to determine XiaoHongShu users'opinions about feminism-related discussion about Barbie movie. In the third step, context analysis are used to determine the impact of feminist topics related to Barbie movie on XiaoHongShu on its users through the information obtained from semistructured interviews and questionnaires. --- RESULTS AND DISCUSSION Data Description Figure 1 shows that 85.78 per cent of the respondents to the questionnaire were female and 14.22 per cent were male respondents. The age distribution shows a decreasing distribution centred on the age stage of 18-24 years old, and the demographic characteristics basically conform to the overall characteristics of the core user group of XiaoHongShu. The overall overview and basic information of this sample questionnaire is given below: The educational level of undergraduate education is the main group of people, accounting for 72.44% of the total, followed by master's degree , and doctoral degree accounted for 2.67% only. --- Text mining results Feminist relevant topics in the "Barbie" movie This study summarizes the keywords and content of feminism-related XiaoHongShu's posts about the "Barbie" movie. Eleven categories are classified: gender consciousness and self-perception, gender equality and affirmative action, gender discrimination, gender violence, gender roles, body perception and self-confidence, gender image, gender economics, female autonomy, female bonds and friendship, and the others. Gender Awareness and Self-Awareness This classification mainly deals with women's awareness of gender differences in society, culture, and product design and how these differences have affected their lives and experiences; the female situation, the shackles compliance training for women in society, and the gender value constraints. Calls for women to accept themselves, to know and love themselves. Gender Equality and Affirmative Action This category is mainly about protecting women's basic rights and interests ; encouraging female students to speak up, share their experiences, discuss, and criticize, and other related content. and other related content, in this study, the participation of XiaoHongShu in the discussion of political topics or public issues will also be categorized into this classification; encouraging the construction of a non-patriarchal, non-matriarchal, and egalitarian society; Gender discrimination This classification is mainly focuses on several major topics such as employment discrimination, unfair gender distribution of educational r e s o u r c e s , a n d f e m a l e c h a s t i t y d i s c r i m i n a t i o n . Gender violence This classification is gender-based violence, including but not limited to sexual assault, sexual harassment, domestic violence, male coagulation, female competition under the discipline of patriarchy, etc. In the content analysis of the XiaoHongShu, there are also emerging issues such as cyber harassment covered; 3 above is a visual display of the words mentioned most frequently in user's posts and comments. --- Figure 1-4 Feminist word frequency chart of "Barbie" Movie in XiaoHongShu Users attach importance to feminism-related words such as "female", "patriarchy", feminism", "perfect". These keywords cover 10 categories of topics related to feminism in Barbie's movie by XiaoHongShu's users. --- Sentiment analysis The sentiment of posts and comments extracted by Baidu NLP API. For the feminism-related discussion on XiaoHongShu. Results are shown in Figure 3 with the following observations. It was found that the sentiment tendencies of XiaoHongShu users towards feminismrelated discussion were skewed positive, and neutral sentiments were less expressed. Besides, most of the respondents of questionnaire was show their positive attitude, some of them believe that XiaoHongShu has a positive effect on the dissemination of feminist view and affirms that feminist discourses related to film on XiaoHongSHu will have some degree of influence on the discussion of feminism in society. --- Figure 1-5 Emotional attributes of posts and emotional tendency of comments for Barbie movie in XiaoHongShu However, the results of the questionnaire showed that, excluding those who expressed positive attitudes, the rest were neutral, whereas for the content analysis of the posts and comments, about one-third of them have a negative attitude towards feminism-related discussion. --- Figure 1-5 Questionnaire Respondents' Emotional Tendencies Toward Topics Related to Barbie Movie Feminism More than 90 per cent of XiaoHongShu users who have seen Barbie's film and posted about it said that the emotional words they used to express their attitudes in the discussion were "Encourage and support", and about a third of the users' attitudes in their posts were "Humor", "Angry" and "Concern" in order. The following are typical positive evaluations: "This film can be used as a feminist primer or a feminist universal values propaganda film.","This film is not just for women, it's to tell the society that everyone is an individual, you are not dependent on anyone and it has nothing to do with gender", the value of life should be to try to be everything you want to be". "The point that particularly struck me after watching Barbie was the fact that women have always given their all to create a world for women." Negative comments on the film's feminist-related topics are not negligible. The following are typical negative evaluations: "This film create a situation where men and women are pitted against each other", "There's also too little shown of the difficult parts of real-world women","The short-lived "patriarchal kingdom of Ken" in "Barbie World" is a childish, even infantilised male compared to reality.""The film seems to have been deliberately dumbed down." --- The Role of Social Media for Feminist Communication In the analysis of questionnaire, more than 91% believed that social media platforms such as Xiaohongshu had a positive effect on the dissemination of feminist views. 3% believed that it did not, and 5% said they were not sure. These respondents believe that feminist discourse on Xiaohongshu has increased attention to feminist issues , raised public awareness of feminism , facilitated social discussions on gender equality , and triggered reflections on sexism . The social media's big data push mechanism divides the audience groups of feminist topics, resulting in a stratified phenomenon of feminism conveyed by social media, with both deep and shallow. While Barbie is marketed to the public, users with different depths and shades of feminist interpretations watch a feminist-colored movie at the same time, and this context is one of the reasons for the mixed reviews of Barbie on Xiaohongshu. In the interview, five respondents add detailed views: "Women's rights have been emphasized nowadays, but it does not mean that some women can use women's rights as 'women's fists' to play on the theme. Women do have the right to be treated the same as men, but at the same time, they should not discriminate against all men and call for people not to fall in love and not to get married" , "There are many different kinds of men and women, so we need to be more discerning, and there are not a few of them who want to just have a bite of the hot meal." , "But very few people talk about how to talk about feminism. Heterosexuality how to enter into marriage how to procreate" , "Gender antagonism counts a little bit yet! When I worked on the Korean feminist theme, I read some interesting quotes: "Men feel vulnerable in the process of being disempowered, and patriarchy doesn't seem to be as good as it once promised" , "There is some influence, but the audience is limited, and the social media has a lot to say about it. media's big data push mechanism divides the audience groups of feminist topics, resulting in a layered phenomenon of feminism conveyed by social media, with deep and shallow." .While Barbie is marketed to the public, users with different depths and shades of feminist interpretations watch a feminist-colored movie at the same time, and this context is one of the reasons for the mixed reviews of Barbie on Xiaohongshu." The majority of the respondents believed that the feminism-related discussions had an impact on their opinions or behaviors . They believe that these discussions have, to varying degrees, made them more aware of gender equality, inspired a desire for selffulfillment, increased awareness of gender stereotypes, triggered thinking about the image of women in the media, and deepened their support for women's rights and interests in order. In the interview, two respondents explained their changes in other aspects: "It has made me realize that as a women, we have a lot of autonomy and that they can give value to themselves instead of being restricted and limited by patriarchy", "It has made me understand that women are a situation. that being female is a situation." .At the behavioral level, more than 65% believe that the movie has inspired their own social engagement, and 40-50% believe that it has influenced their philosophy of family education , inspired artistic creation and changed their consume attitudes . --- Personal context shapes perspectives The study found that users in older age groups appeared to be more conservative about the role of Xiaohongshu, on the development of feminism in society as opposed to younger people. Users aged 18-25 are relatively optimistic that feminist topics on Xiaohongshu have a positive effect on the development of feminism in society, with more than 90% of respondents. On the contrary, more than a quarter of respondents over 35 years old thought that the impact was average as well as small . This is also reflected in the fact that nearly 30% of them answered "No" to the question "Do these feminist discussions have an impact on opinions or behaviors?". Surprisingly, the authors predicted that respondents in developed region would be more knowledgeable about feminism compared to Tier 3,4 or 5 respondents. However, it turned out that there was no significant difference in the level of knowledge about feminism between these two segments of respondents. --- Conclusion Social media enables individuals to recognize the importance of feminism. The research in this paper focuses on this particular topic, emphasizing how users on these platforms share their experiences and respond to the experiences shared by other users. This research suggests that the Xiaohongshu platform enables individuals to share their personal stories in depth, with a tendency to court other users to discover the power of women and increase gender equality awareness. Disregarding the negativity towards different aspects of these personal experiences, the individuals on these platforms are very hopeful that these stories will lead to real change in current society. I hope that my work helps to start a discussion between individuals in society as well as researchers and legislators to come up with new laws and regulations to protect female's right in society.

Social media platforms are revolutionizing the way users communicate by increasing the exposure to highly stigmatized issues in the society. Feminism is one such topic that recently took over social media. This paper studies the attributes of XiaoHongShu user toward the feminism related topics, by content analysis of the online posts via #Barbie on XiaoHongShu, a sharing platform. The findings show that majority of XiaoHongShu user have positive attitudes to feminism-related topics in Barbie movie by analyzing the posts and comments are shared on this platform. Besides, XiaoHongShu commentators are mainly focused on eleven topics related to feminism: gender consciousness and self-perception, gender equality and affirmative action, gender discrimination, gender violence, gender roles, body perception and self-confidence, gender image, gender economics, female autonomy, female bonds and friendship and others. This research indicated that social media platforms have proven to be fertile ground for movements such as feminism, facilitating the dissemination of perspectives and the fostering of dialogue.

Introduction In the near future, in order to be effectively integrated into human environments, robots should be able to interact using an adequate level of cognition. Such cognition should be flexible enough to allow the robots to understand human actions, store knowledge efficiently and react accordingly, taking into account changes in context. Among artificial intelligence techniques and machine learning methods, a wide variety of techniques are effective under determined conditions. For example, neural networks can approximate non-linear functions, whereas reinforcement learning can effectively solve game playing and pathfinding problems. Unsupervised learning, on the contrary, has the advantage of not needing labelled data for a training set. However, depending on the specific problem, most of these techniques may be inefficient. In general, the "no free lunch" theorem applies to machine learning [1], as for each specific problem the most fitting technique is going to be different. Robots should learn from experience and from interactions with other agents they encounter in their environment in a similar way as animals, including humans. From the point of view of learning algorithms, this setting imposes certain constraints which often do not hold for mainstream machine learning applications. Such constraints include finite storage and memory, and the need to learn incrementally, by modifying behavior after each or every few experiences. With such conditions, online learning is the natural approach for robots [2]. --- Objectives of This Paper The problem we are addressing involves learning through data extracted from heterogeneous sources such as studies from literature of human sciences. In this regard, we believe that the quantitative approach has an advantage over purely qualitative descriptions, such as symbolic learning techniques, because the application of a probabilistic model instead of a deterministic one allows the efficient use of all the information available; we therefore refer to statistical learning rather than machine learning. A probabilistic approach has been recently attempted in a study by Myagmarjav and Sridharan [15], where knowledge in human-robot interaction is acquired through selective active learning, using probabilities and queries. Lepora et al. also used the naive Bayes classifier in real world tasks on a moving robot with whiskers [16,17]. Our method is close to these works. Our objectives are the following: ‚ formalize empirical social behaviors into a dataset ‚ apply a learning technique to the dataset of correlations of features and actions ‚ make the robot actually learn socially appropriate actions through online adaptation Compared to existing research, limited in the use of empirical results of social science, the main contribution of this paper is to show how, through an algorithm based on the naive Bayes classifier, heterogeneous and incomplete knowledge from social robotics can be used for statistical learning. Experiments are shown as examples of application, to serve as a model in future similar studies in the same field. Two applications are described: the implementation of a greeting selection system for a humanoid robot , and the implementation of a behaviour selection system for attracting humans' attention . In both cases, the robot should be able to adapt its action selection to the evolving context, learning respectively an appropriate choice of gesture, and an appropriate choice of attention-attracting behavior. Merging empirical datasets that list correlations of features and actions with quantitative experimental data and their subsequent learning behavior is a task that poses several challenges, which can be addressed by our method. The rest of the paper is organized as follows: in Section 2 we describe the concept of the algorithm; in Section 3 we show two possible applications; Section 4 concludes the paper. --- Methods --- Generic Model We want to implement a system that enables effective online learning for a robot by using data extracted from literature of human sciences as well as experimental data. In Figure 1, the concept is described: a table is made out of training data; features' values are given as input, and the classifier outputs a chosen class that corresponds to an action to be implemented in the robot. The action is performed and evaluated through either questionnaires or experimental measurements. The resultant feedback updates the dataset. Robotics 2016, 5, 6 3 of 21 classifier in real world tasks on a moving robot with whiskers [16,17]. Our method is close to these works. Our objectives are the following:  formalize empirical social behaviors into a dataset  apply a learning technique to the dataset of correlations of features and actions  make the robot actually learn socially appropriate actions through online adaptation Compared to existing research, limited in the use of empirical results of social science, the main contribution of this paper is to show how, through an algorithm based on the naive Bayes classifier, heterogeneous and incomplete knowledge from social robotics can be used for statistical learning. Experiments are shown as examples of application, to serve as a model in future similar studies in the same field. Two applications are described: the implementation of a greeting selection system for a humanoid robot , and the implementation of a behaviour selection system for attracting humans' attention . In both cases, the robot should be able to adapt its action selection to the evolving context, learning respectively an appropriate choice of gesture, and an appropriate choice of attention-attracting behavior. Merging empirical datasets that list correlations of features and actions with quantitative experimental data and their subsequent learning behavior is a task that poses several challenges, which can be addressed by our method. The rest of the paper is organized as follows: in Section 2 we describe the concept of the algorithm; in Section 3 we show two possible applications; Section 4 concludes the paper. --- Methods --- Generic Model We want to implement a system that enables effective online learning for a robot by using data extracted from literature of human sciences as well as experimental data. In Figure 1, the concept is described: a table is made out of training data; features' values are given as input, and the classifier outputs a chosen class that corresponds to an action to be implemented in the robot. The action is performed and evaluated through either questionnaires or experimental measurements. The resultant feedback updates the dataset. --- Classification of Training Data --- Characteristics of Data In human-robot interaction and in social robotics, it is common to work with quantitative as well as qualitative data extracted from literature of studies of human sciences such as sociology, anatomy, anthropology, and so on. From these data we can extract features and classes; however, there are usually some properties that limit the possible choice of classifying methods: --- Classification of Training Data --- Characteristics of Data In human-robot interaction and in social robotics, it is common to work with quantitative as well as qualitative data extracted from literature of studies of human sciences such as sociology, anatomy, anthropology, and so on. From these data we can extract features and classes; however, there are usually some properties that limit the possible choice of classifying methods: --- ‚ Heterogeneous data types: some features are binary values; some other are continuous but can be discretized; some others are categorical and not ordinal. Classes also can be represented in percentages or as absolute values, and features may be associated with more than one class to different degrees. Baynesian networks have been used to synthesize the findings from these separate studies of sociology, biology and economics [20], and can be used for representing and predicting social behaviors [21]. However, they assume parent/child relations between variables, while in our problem we are assuming independence between class-condition feature probabilities. --- ‚ Incompleteness: studies are usually focused on a single or a couple of specific variables, whereas our model involves more variables. For example, a study with gender as a variable, may fix some variables while not specifying others which might be of interest. Missing data can make it difficult to use techniques for classification such as neural networks or to even just represent it in a space with principal component analysis. See [22] for a review of the problem from a statistical perspective. ‚ Set size: Small datasets limit the choice of training methods. Data from different sources can be integrated in order to expand the training dataset, but this will also cause the incompleteness problem stated above. In particular, when integrating human studies data with experimental data, we receive the data incrementally . Online learning methods fit this kind of problem. Small experimental datasets have been used in modelling of complex processes successfully in [23], but the composition of the training datasets becomes critical, with designed sets performing better than random ones. Other learning models were compared for problems with small datasets in [24], where mixed results were found dependent on feature selection, and naive Bayes and its multinomial variation [25] were reported to outperform the others, including support vector machines, in many conditions. Given these properties, we believe that the naive Bayes classifier is a good choice for dealing with this kind of data. Naive Bayes can easily handle weighted data, incomplete data, small datasets, and categorical variables. --- Naive Bayes First, let us define the sets of features of our problem f = {f 1 , ..., f I } and the sets of classes C = {C 1 , ..., C J }, given I number of features and J number of classes. The dataset is composed of K elements < f , C >, resulting in {<f , C >; ...; <f , C >}. Equation represents the generic formula of posterior probability for the class C j and the feature f i . P `Cj ˇˇf ˘9P `Cj ˘ź i P `fi ˇˇC j ˘ Naive Bayes is a simple generative probabilistic classification model which assumes independence between features of the objects to be classified [26]. Therefore, the naive Bayes classifier applies Bayes's theorem with the assumption that the presence or absence of each feature is unrelated to other features. Its effectiveness in classification has been proven despite its independence assumption [27]. Moreover, naive Bayes only requires a small amount of training data to estimate the parameters necessary for classification. These characteristics make it appropriate for the features of many problems in social robotics. Under naive Bayes we label object C* according to Equation : C˚" arg max C j P `Cj ˘ź i P `fi ˇˇC j ˘ where P is the prior probability of class C j and P is the likelihood of class C j with respect to feature f i . In general, these probabilities are estimated from the feature-class co-occurrence count table, e.g., using the maximum likelihood estimates as in Equation : P `fi ˇˇC j ˘" count `fi , C j count `Cj ˘ The prior probabilities can be similarly derived from a count table. Thus these count tables form the sufficient statistics for the naive Bayes model. Count tables can be easily updated online, by simply incrementing class-feature counters, as each labelled example is processed, and the updated model can be immediately used for classifying new objects. In fact, the naive Bayes's sufficient statistics form an additive monoid, and admit both efficient online training and efficient parallel learning [28]. --- Conversion of Heterogeneous Data into a Dataset When handling real data from different sources, we should distinguish the types of studies we are using in order to clearly define a semantics of weights w j that can be associated with classes C j and build a count table which will serve as a batch for training. Data can appear in different types, such as: A percentage in which all the classes of our problem are considered . A percentage in which one or more classes of our problem are not considered. A percentage in which one of the classes may include the classes of our problem which are not specifically mentioned. Absolute values of measurement without a known scale . Absolute values of measurement, between a priori maximum and minimum values . Likert scales and differential semantic scales fall into this category. Case is the simplest, as percentages are directly turned into weights between 0 and 1. For example, in a study in which 55% of the population belongs to class C A , its w A will be 0.55. For case , let us now consider the following simple sample data: ‚ Study 1: when feature 2 is 0, 55% of the population belongs to class C A and the rest to class C B , whereas when feature 2 is 1, the results change to 39% and 61%. ‚ Study 2: under different conditions and feature 3 fixed to 0, 50% of the population belongs to class C B , and the rest to classes C A and C C . In Table 1, we organized these data, marking the field as "unknown" where variables are not considered in the study. When some conditions significantly change between two studies, the index of the considered study itself should be considered a feature. Normalization is then necessary, because data refer to different scales in which different classes were involved. In this case, class C C is not present in the first study. Therefore, assuming a uniform prior estimation for the class C C as 1/J, where J is the number of classes, the weights for C A and C B can be normalized to sum 1. In the above case where w A = 0.39 and w B = 0.61, they will be reduced to 2/3 , becoming w A = 0.26 and w B = 0.41. The way of assuming a prior estimation for the missing class depends on the interpretation of the data, and cases , and differ from . In Figure 2 we show an excerpt from three different empirical studies [29][30][31] on asymmetry in facial expressions which provide different data, respectively focusing on culture, emotion, and its background meaning; asymmetry, gender and emotions; and emotional valence, gender and asymmetry. Typically, a possible purpose of gathering these data could be making a robot capable of autonomously determining when an asymmetrical facial expression is appropriate. The way of assuming a prior estimation for the missing class depends on the interpretation of the data, and cases , and differ from . In Figure 2 we show an excerpt from three different empirical studies [29][30][31] on asymmetry in facial expressions which provide different data, respectively focusing on culture, emotion, and its background meaning; asymmetry, gender and emotions; and emotional valence, gender and asymmetry. Typically, a possible purpose of gathering these data could be making a robot capable of autonomously determining when an asymmetrical facial expression is appropriate. In case it may be desirable to split the remaining part to all the classes not specifically mentioned. For example, if the data reports 58.3% class CA, 16.7% class CB, 11.1% class CC, and the remaining 13.9% other, supposing that our problem has five classes, the latter part can be approximated as the sum of the weights of classes CD and CE. Filling wD = 0.0695 and wE = 0.0695 and adding this data to the dataset will force these weights to be low, where a uniform estimation of 0.25 would be considered too high. In case , in which, as in Figure 2, the number of subjects are counted, it is enough to apply the same method as , assuming a uniform prior estimation for the missing classes as 1/J. Figure 2e shows an example of values measured in pixels, therefore having a maximum and minimum value: data vary within that scale. In this case it may be more reasonable to assign the average value of the scale to unknown classes. A further example with simpler data can clarify better the reason of this approach in case . In a problem with four classes with two of them unknown, a data vector could be <18/30, 24/30, ?, ?>, which equals <0.6, 0.8, ?, ?>. Fixing a uniform estimate of 0.25 ) for wC and wD, and then normalizing only wA and wB, the weights vector would result in <0.21, 0.29, 0.25, 0.25>: having wC and wD higher than wA may not be reasonable. Instead, assuming data for CC and CD as 15/30 , adding the resulting wC = 0.5 and wD = 0.5, to the dataset and then normalizing it will force them to be higher: the weights vector would be <0.25, 0.33, 0.21, 0.21>. How the relative weight of wA changes compared to unknown classes proves the importance of the semantics. In all the above cases, after calculating the unknown weights, their addition to the dataset is not strictly necessary for the naive Bayes classifier to work, but it does become necessary depending on the policy described in Section 2.6.1. In case it may be desirable to split the remaining part to all the classes not specifically mentioned. For example, if the data reports 58.3% class C A , 16.7% class C B , 11.1% class C C , and the remaining 13.9% other, supposing that our problem has five classes, the latter part can be approximated as the sum of the weights of classes C D and C E . Filling w D = 0.0695 and w E = 0.0695 and adding this data to the dataset will force these weights to be low, where a uniform estimation of 0.25 would be considered too high. In case , in which, as in Figure 2, the number of subjects are counted, it is enough to apply the same method as , assuming a uniform prior estimation for the missing classes as 1/J. Figure 2e shows an example of values measured in pixels, therefore having a maximum and minimum value: data vary within that scale. In this case it may be more reasonable to assign the average value of the scale to unknown classes. A further example with simpler data can clarify better the reason of this approach in case . In a problem with four classes with two of them unknown, a data vector could be <18/30, 24/30, ?, ?>, which equals <0.6, 0.8, ?, ?>. Fixing a uniform estimate of 0.25 ) for w C and w D, and then normalizing only w A and w B , the weights vector would result in <0.21, 0.29, 0.25, 0.25>: having w C and w D higher than w A may not be reasonable. Instead, assuming data for C C and C D as 15/30 , adding the resulting w C = 0.5 and w D = 0.5, to the dataset and then normalizing it will force them to be higher: the weights vector would be <0.25, 0.33, 0.21, 0.21>. How the relative weight of w A changes compared to unknown classes proves the importance of the semantics. In all the above cases, after calculating the unknown weights, their addition to the dataset is not strictly necessary for the naive Bayes classifier to work, but it does become necessary depending on the policy described in Section 2.6.1. --- Customisation of Naive Bayes Formulas In our naive Bayes classifier, the selection of the class C* is done through a formula different from the standard one. --- Conditional Probability First, the standard formula of conditional probability is rewritten in Equation , taking into account the fact that class membership is based on weights w. The probability of f i , the i-th feature of f, being equal to a value v, is found through the sum, for each k-th sample < f , C > in the dataset, of the weights that are defined when f i = v through a multiplier δ . The formula of class priors P is rewritten in the same way in Equation . P `fi " v ˇˇC j ˘" K ř k"1 ´δpkq pvq ¨wpkq j K ř k"1 w pkq j P `Cj ˘" K ř k"1 w pkq j K The best class C* is selected through Equation : C˚" arg max C j P `Cj ˘I ź i"1 P `fi " v ˇˇC j ˘ In our customized formula ), we leave class priors P out. This additional assumption is made because we do not want to give more weight to more common class a priori, so only independent probability distributions are considered. --- C˚" arg max C j I ź i"1 P `fi " v ˇˇC j ˘ Leaving out the class priors is equivalent to assuming a uniform probability distribution over the classes. Class distributions estimated from very small samples are inherently noisy, and we believe using a flat prior here is a legitimate choice. An example can clarify the need for this modification. The typical case is when having a very small dataset, like the one in Table 2, in which one class appeared more times than the others. Using the classification formula of Equation , the mapping of the maximum likelihoods for each possible combination of features would result as in Table 3 on the left. The bias towards class 2 comes from the priors P, which would be <0.2501, 0.3749, 0.2502, 0.2500>. Without such bias, the mapping will appear as in Table 3 on the right. Extending the concept to a bigger mapping, it is easy to predict that priors can unbalance it and penalize less common classes, which may never be selected. --- With Lass Priors f2 = 0 f3 = 0 f2 = 0 f3 = 1 f2 = 1 f3 = 0 f2 = 1 f3 = 1 f1 = 0 C* = 2 C* = 3 C* = 2 C* = 2 f1 = 1 C* = 2 C* = 2 C* = 2 C* = 2 Without Class Priors f2 = 0 f3 = 0 f2 = 0 f3 = 1 f2 = 1 f3 = 0 f2 = 1 f3 = 1 f1 = 0 C* = 3 C* = 3 C* = 2 C* = 3 f1 = 1 C* = 2 C* = 3 C* = 2 C* = 2 2.4.2 --- . Smoothing Technique Conditional probabilities P are balanced out through an add- smoothing technique, namely the use of m-estimate [32], which avoids the inconveniences that may happen when the number of total occurrences of a feature under certain conditions equals 0. In generic terms, for estimating conditional probabilities in a table of data, instead of using the standard formula in Equation , the formula in Equation is used. The probability of A given B does not depend only on the joint probability of A and B divided by the probability of B, but is balanced out by p and m. We need p as a non-zero prior estimate for P, which we suppose uniformly distributed, and a number m that says how confident we are of this prior estimate p. The value m is defined as the equivalent sample size of m-estimate formula. It can be tuned on a development set; usually a small number is convenient for small sets of data, in order to balance out probability from training data compared to the weight of p. The value p is the uniform prior estimation of the probability. It is usually set as 1/J, where J is the number of classes.       B P B A P B A P   |       m B P p m B A P B A P      | As a result, the generic formula of the classifier is shown in Equation :     m w p m w v C v f P K k k j K k k j k j i           1 ) --- Incomplete Data As we may have to deal incomplete data, the multiplier  , a function introduced for the calculation of the joint probability of a certain feature with a certain class, can be customized as well, as in Equation . Depending on the quantity of incomplete training data,  can be defined arbitrarily. It can be 0.5 or even less, in case incomplete data is considered not reliable.         otherwise 0 undefined 5 . 0 1 ) --- Adaptation through Rewards In our model, the representation of knowledge has to be adaptive to feedback collected from 2.4.2. Smoothing Technique Conditional probabilities P are balanced out through an add-ε smoothing technique, namely the use of m-estimate [32], which avoids the inconveniences that may happen when the number of total occurrences of a feature under certain conditions equals 0. In generic terms, for estimating conditional probabilities in a table of data, instead of using the standard formula in Equation , the formula in Equation is used. The probability of A given B does not depend only on the joint probability of A and B divided by the probability of B, but is balanced out by p and m. We need p as a non-zero prior estimate for P, which we suppose uniformly distributed, and a number m that says how confident we are of this prior estimate p. The value m is defined as the equivalent sample size of m-estimate formula. It can be tuned on a development set; usually a small number is convenient for small sets of data, in order to balance out probability from training data compared to the weight of p. The value p is the uniform prior estimation of the probability. It is usually set as 1/J, where J is the number of classes. --- P pA|Bq " P pA X Bq P pBq P pA|Bq " P pA X Bq `m ¨p P pBq `m As a result, the generic formula of the classifier is shown in Equation : P `fi " v ˇˇC j ˘" K ř k"1 ´δpkq pvq ¨wpkq j ¯`m ¨p K ř k"1 w pkq j `m --- Incomplete Data As we may have to deal incomplete data, the multiplier δ , a function introduced for the calculation of the joint probability of a certain feature with a certain class, can be customized as well, as in Equation . Depending on the quantity of incomplete training data, δ can be defined arbitrarily. It can be 0.5 or even less, in case incomplete data is considered not reliable. δ pkq pvq " $ ' ' & ' ' % 1 f pkq i " v 0.5 f pkq i " undefined 0 otherwise Robotics 2016, 5, 6 9 of 21 --- Adaptation through Rewards In our model, the representation of knowledge has to be adaptive to feedback collected from experimental data. Therefore, the model includes rewards or penalties depending on the feedback. Ideally, the algorithm has to adapt quickly. As in human-robot interaction where we are dealing with real world problems rather than abstract ones, the desired amount of iterations necessary for a complete adaptation from the initial mapping to another one should be comparable to the number of interactions humans need to understand behavior rules. The process should not require hundreds or thousands of steps. Each time a class is selected and an action is executed by the robot, probabilities of the current data sample <f *, C*> at step T are considered weights and updated to the new weights at step T + 1 through the formula in Equation . wpT `1q " wpTq `l ¨r ¨d The learning rate l, the reward factor r and the value d depend on the specific implementation. For instance, if the feedback data is obtained from 5-point Likert scales, r could be a value among {´1, ´0.5, 0, 0.5, 1} depending on the questionnaire results, whereas d could be 1´w or w depending on the questionnaire feedback being >3 or <3 . Otherwise, if feedback is obtained from experimental data such as measurement of participant's response of some kind, the formula for r could be tailored to be proportional to performance such as the success of an action, the number of hits, or inversely proportional to negative performance such as delay of response. Through the combination of these factors, a cost/reward function can be tailored for the experiment. The learning rate l can be kept at 1 for assigning equal importance to each step. The adapting process can be forcefully led to convergence if l is a decreasing function instead , when real world scenario constraints make it necessary. Rewards are commonly used in reinforcement learning too, where transitions from states to other states happen through a range of actions: rewards affect good states or actions when the goal is reached. In our case, rewards modify the weight actions associated to states, but there is no transition between one state and another: one whole iteration consists in just one state, defined by current feature values. --- Other Policies --- Class Selection Whenever a new vector of input features f* has to be classified, the following cases may happen: --- ‚ The set of features f* is not present in the dataset. In this case, naive Bayes is calculated. --- ‚ The set of features f* is already present in the dataset and the vector is associated with some weights. In this case, classification can be done either by: o using the current weights: generically speaking, in order for this option to be possible, data has to be consistent within all classes for f*, with missing data previously filled as explained in Section 2.3. o ignoring the current weights, and recalculating the probabilities through naive Bayes . Regardless of the vector of the current input features f* corresponding to a vector of new probabilities or to a vector of previous weights, in either case there are several possible policies for the selection of the output class C*: --- ‚ The simplest solution is to get the maximum value, as in the standard Equation and Equation . --- ‚ Another possibility, which gives more emphasis to exploration, is to use a ε-greedy policy: with 0 < ε < 1, C* is the argmax with ε probability, and will be a random selection with 1´ε probability. ‚ C* can be assigned any of the possible classes, with probability proportional to the list of weights. For example, in a weight vector <0.4, 0.2, 0.1, 0.3>, the first class would be selected with 0.4 probability. --- Stopping Conditions The adaptation process can potentially be continuous, or can be stopped depending on criteria that are up to the experimenter. When stopping conditions are satisfied, rewards will no longer apply, and the system will be considered fully trained. One possible method is to verify the maximum likelihoods for each possible combination of features. Making a mapping of such values, like in Table 3, we form a table in which each cell represents a "state" and is associated with an "action" represented by the class with maximum likelihood C*. Then, stopping conditions can be triggered when changes of C* are stabilized. This condition is verified when the following two conditions and ) are true at the same time. One condition ensures that all states have been explored once , C >, in which f corresponds to that features vector). The other condition checks whether the moving average of C* changes during the latest W iterations to decrease below a threshold. @ f , Dk : f pkq " f T ř t"T´W`1 σ C σ TOT W ď θ In Equation , σ C is the number of states in which C* changed; σ TOT is the total number of states. The threshold θ can be set as q σ TOT . --- Results and Discussion In this section we will describe two applications of the algorithm. We will not enter into detail of the research behind those experiments, but rather show the effectiveness of our method. In both applications, some details of the algorithm have been customized. Discussion follows in the last part. --- Application 1: Greeting Interaction --- Purpose of the Study As humans, we greet each other following sometimes complex or unclear rules which vary by country or even by region. Nevertheless, when exposed to a new culture, we are able to adapt to a new set of rules after only a few interactions. The purpose of this study was to make a humanoid robot adapt to the German way of greeting, while being initially trained with Japanese social data about greeting rules. Culture differences are indeed important for ensuring technology acceptance [34], including more complex machines such as robots. In a recent work, Heenan et al. made a state machine model for greetings comprehensive of the approach phase [35]; however, it does not take cultural factors into consideration, which is the focus of this experiment. ARMAR-III [36], a humanoid robot designed for close cooperation with humans, was used in this experiment, which took place in the room shown in Figure 3. --- Greeting Selection System The implementation of the greeting selection system is composed of two parts regarding gesture and speech; in Figure 4 and in the next paragraph we describe only the part related to gestures. The system takes context data as input features and produces the appropriate robot posture for that input. Robot posture configuration is implemented through a process described in [18]. The values of features and classes regarding greeting gestures is summarized in Table 4. As the experiment consists of adapting from knowledge extracted from one culture to another , culture acts as a discriminant rather than being an input feature. In this way, for different cultures, there will be different mappings. Mappings are updated using experimental data in the form of questionnaires filled by experiment participants. In order to be initialized, the only needed training set is the Japanese one: before beginning the experiment, a table made from Japanese sociology data and a mapping called M0J was built. After interacting with German people, the resulting adapted mapping M1 is expected --- Greeting Selection System The implementation of the greeting selection system is composed of two parts regarding gesture and speech; in Figure 4 and in the next paragraph we describe only the part related to gestures. --- Greeting Selection System The implementation of the greeting selection system is composed of two parts regarding gesture and speech; in Figure 4 and in the next paragraph we describe only the part related to gestures. The system takes context data as input features and produces the appropriate robot posture for that input. Robot posture configuration is implemented through a process described in [18]. The values of features and classes regarding greeting gestures is summarized in Table 4. As the experiment consists of adapting from knowledge extracted from one culture to another , culture acts as a discriminant rather than being an input feature. In this way, for different cultures, there will be different mappings. Mappings are updated using experimental data in the form of questionnaires filled by experiment participants. In order to be initialized, the only needed training set is the Japanese one: before beginning the experiment, a table made from Japanese sociology data and a mapping called M0J was built. After interacting with German people, the resulting adapted mapping M1 is expected The system takes context data as input features and produces the appropriate robot posture for that input. Robot posture configuration is implemented through a process described in [18]. The values of features and classes regarding greeting gestures is summarized in Table 4. As the experiment consists of adapting from knowledge extracted from one culture to another , culture acts as a discriminant rather than being an input feature. In this way, for different cultures, there will be different mappings. Mappings are updated using experimental data in the form of questionnaires filled by experiment participants. In order to be initialized, the only needed training set is the Japanese one: before beginning the experiment, a table made from Japanese sociology data and a mapping called M0J was built. After interacting with German people, the resulting adapted mapping M1 is expected to represent German rules of greeting interaction. A mapping M0G made from a table of German sociology data of gestures was built, too, and only used for validation. Our hypothesis is that M1 will be closer to M0G than to M0J. 5, let us summarize the concept of the algorithm and the way rewards are calculated: 1. The dataset is built from training data: weights w j corresponds to each vector added. --- 2. Whenever a new feature vector f * is given as input, it is checked whether it is already contained in the dataset or not. In the former case, the weights are directly read from the dataset and the greeting corresponding to the highest weight is selected; in the latter case, classification is calculated through naive Bayes. --- 3. In the naive Bayes classifier, the best greeting g* chooses the greeting g j that has the highest probability, calculated from its weights w i , using the add-ε smoothing technique and a multiplier δ, as in Equation . --- 4. Once the greeting is chosen, the resulting probabilities are normalized. The stopping condition is then calculated as in Equations and . If all conditions are satisfied, no updating will be performed, as the mapping has already been stabilized. --- 5. Otherwise, the next step consists of getting the evaluation from the participant for the current selected greeting g*, whether appropriate or not according to the participant's culture, to the current context f*. On a scale from 1 to 5, if it is greater than 3, the weight of that greeting for the present context is multiplied by a positive reward. If less than 3, is it multiplied by a negative reward; if it is exactly 3, nothing is done. All vectors f start with a counter s set to 0, and every time one vector is processed, its counter increases and makes the learning factor decrease, dampening the magnitude of the rewards. 6. If the evaluation is less than or equal to 3, the participant is also asked to indicate which greeting type instead would have been appropriate in this context f*. The weight of that greeting g** is boosted. 7. The participant is finally asked to indicate, for the chosen greeting type g*, which context f** would have sounded appropriate. If there is any, the weights corresponding to f** are updated with a boost for the current greeting; otherwise, if g* is judged inappropriate in any case, all the weights receive a negative reward. The vector f** is added to the dataset if new, or updated if already existing. 8. All the new weights in the dataset are normalized . At this point, the algorithm is ready for a new input, and goes back to step 1. The next time that the input feature vector is the same as the one just added, the weights will be directly used . weights receive a negative reward. The vector f** is added to the dataset if new, or updated if already existing. 8. All the new weights in the dataset are normalized . At this point, the algorithm is ready for a new input, and goes back to step 1. The next time that the input feature vector is the same as the one just added, the weights will be directly used . As explained in steps 4, 5 and 6, the questionnaire is made up of three questions; this means that at the same time the rewards may affect directly three weights in two cells of the mapping , making the learning process much faster. f i i-th feature of f J = 5 Number of possible greeting choices f k-th feature vector in the dataset j = 1 … J Index of greetings f * Feature vector selected by the classifier g j j-th greeting in G f ** Feature vector suggested by the participant to match g * g Greeting at the k-th element in the dataset v Value that can be taken by a feature f i g * Greeting chosen by the classifier w j Learning factor. High at the beginning and decreases following the e -x curve S Stopping conditions as in Equations and , with W = 10 and q = 2/ TOT  = {1, 0.2, 0} Multiplier for incomplete data, as in Equation . Set empirically low in case of undefined f i , due to the high quantity of incomplete training data --- Experiment Results and Validation In this experiment, 18 German people of different ages, gender, workplace, and knowledge of the robot were invited to participate. Some of them participated in a second interaction. At the end, all the feature values had the chance to be classified at least once except for "Location = Private." As explained in steps 4, 5 and 6, the questionnaire is made up of three questions; this means that at the same time the rewards may affect directly three weights in two cells of the mapping , making the learning process much faster. --- S Stopping conditions as in Equations and , with W = 10 and q = 2/σ TOT δ = {1, 0.2, 0} Multiplier for incomplete data, as in Equation . Set empiricallylow in case of undefined f i , due to the high quantity of incomplete training data --- Experiment Design The robot Nao is placed in a room , which is adjusted to the actual manipulated conditions which are the features in Table 8 . While the participant is concentrated watching TV, at random intervals one of the behaviors listed in Table 6 will be triggered and Nao will try to attract the person's attention until he/she pauses the TV. --- Settings of the Algorithm The architecture of the algorithm is similar to the one in Section 3.1.3. It can be summarized as follows: 1. The dataset of experience is initially empty. Whenever a new feature vector is given as input, it is checked whether it is already contained in the dataset or not. In the former case, the classification happens reading the weights directly from the dataset; in the latter case, they get assigned the values of probabilities calculated through our customized naive Bayes of Equation . The three experiments mainly differ in: ‚ Features and classes: the room conditions and possible behaviors listed in Table 8 refer to the first session. As all the features are binary, the mapping is composed of 16 possible combinations. The third experiment had a smaller number of features and four behaviors. --- ‚ Measurement: in the first two experiments, feedback is provided by a questionnaire that is filled out every time the TV is paused. It is based on 5-point semantic differential scales, similar to the experiment in Section 3.1. In the third experiment, feedback comes from a cost/reward function calculated from other measurements such as reaction times, head direction, delay and a fixed cost of each of the robot's behaviors. These factors are grouped as reward for action r A , which is positive or null; cost for the robot c R ; and cost for the human c H . --- ‚ Class selection policy: in the third experiment we used leave-one-out cross-validation introduced in Section 2.6.1: classification is never taken directly from the current weights, but naive Bayes probabilities are recalculated every time, leaving the current features' input out of the calculation. --- Settings of the Algorithm The architecture of the algorithm is similar to the one in Section 3.1.3. It can be summarized as follows: 1. The dataset of experience is initially empty. Whenever a new feature vector is given as input, it is checked whether it is already contained in the dataset or not. In the former case, the classification happens reading the weights directly from the dataset; in the latter case, they get assigned the values of probabilities calculated through our customized naive Bayes of Equation . --- 2. Once the behavior b* is chosen and executed, we get the evaluation, on 5-point semantic differential scales, from the participant: a whether b* was effective or not; b if the evaluation was lesser or equal than 3 at point a, which behavior type b** instead would have been appropriate in this context f*; c if the evaluation was lesser or equal than 3 at point a, in which context f** the behavior b* would have been effective. --- 3. Weights are updated through the formula of Equation w = w + l ¨r ¨d where T is the current time step, l = exp is the learning factor , r is the reward factor {´1, ´0.5, 0, 0.5, 1} depending on the rating, and d is 1´w or w depending on the rating being greater/lesser/equal to 3. --- 4. New data obtained from these evaluations are then added to the dataset and normalized. As in the previous experiment, this way of managing the questionnaire allows data from experience to affect the mapping in up to two different cells at the same time. Next, we report the main differences: --- ‚ Unlike in Section 3.1, in which the adaptation process was incremental for all participants, here we ran a separate whole set of interactions for each participant. This makes it possible to distinguish actual learning regardless of personal differences among participants. As for each one we fixed 12 iterations, there were no stopping conditions. --- ‚ There is no batch data for training. The mapping starts untrained, and this brings some complications. Initializing the first input vector with random values makes learning biased towards the classes that are more likely at the very beginning. Subsequent positive reward may cause a lack of exploration. This problem can be solved using a different policy of class selection, as explained in Section 2.6.1, such as ε-greedy, and/or removing the bias of the class priors, as introduced in Section 2.4.1. A stronger effect can even be obtained if the priors are replaced by another function that actuates a counter-bias. --- Results Each of the 23 participants performed 12 repetitions of the interaction. We expected the algorithm to update the mapping and effectively represent participants' preferences. Another 25 participants were used as the control group, receiving six randomly chosen actions instead of those generated from the algorithm. First, we show in Table 9 an example of how mapping can evolve in one iteration. In the situation of the mapping on the left, values have been assigned based on one random input vector . The state gets evaluated: the subject assigns a low score for the behavior 2 , suggesting 1 with maximum score and suggests the state as appropriate for waving. The resulting mapping on the right shows how: other states were affected by the high rating of behavior 1 and 2 for respectively the second and fourth, and for the first and third row; how due to customization of priors in the equation, less likely behaviors may appear again. In order to assess the effectiveness of learning, the final probability matrix distribution and the average rating distribution of every behavior in the questionnaires were compared. A correlation test was conducted and we found a positive correlation , proving that the preferences of the participants were learned. Figures 7 and8 show the variation of average ratings and respective probability distributions for every action. This essentially means that the robot has learned to adapt its attention-attracting behavior selection to the evolving context. --- Discussion --- About this Approach The term "machine learning" was not used in this paper to refer to our solution, which is more appropriately referred to as "statistical learning." We believe the advantages of our approach are its feasibleness and its potential to be used by other researchers, tuning it according to their needs, especially if the datasets are made of heterogeneous or incomplete knowledge, and if the goal is to adapt through experimental data. Other In order to assess the effectiveness of learning, the final probability matrix distribution and the average rating distribution of every behavior in the questionnaires were compared. A correlation test was conducted and we found a positive correlation , proving that the preferences of the participants were learned. Figures 7 and8 show the variation of average ratings and respective probability distributions for every action. This essentially means that the robot has learned to adapt its attention-attracting behavior selection to the evolving context. In order to assess the effectiveness of learning, the final probability matrix distribution and the average rating distribution of every behavior in the questionnaires were compared. A correlation test was conducted and we found a positive correlation , proving that the preferences of the participants were learned. Figures 7 and8 show the variation of average ratings and respective probability distributions for every action. This essentially means that the robot has learned to adapt its attention-attracting behavior selection to the evolving context. --- Discussion --- About this Approach The term "machine learning" was not used in this paper to refer to our solution, which is more appropriately referred to as "statistical learning." We believe the advantages of our approach are its feasibleness and its potential to be used by other researchers, tuning it according to their needs, especially if the datasets are made of heterogeneous or incomplete knowledge, and if the goal is to adapt through experimental data. Other In order to assess the effectiveness of learning, the final probability matrix distribution and the average rating distribution of every behavior in the questionnaires were compared. A correlation test was conducted and we found a positive correlation , proving that the preferences of the participants were learned. Figures 7 and8 show the variation of average ratings and respective probability distributions for every action. This essentially means that the robot has learned to adapt its attention-attracting behavior selection to the evolving context. --- Discussion --- About this Approach The term "machine learning" was not used in this paper to refer to our solution, which is more appropriately referred to as "statistical learning." We believe the advantages of our approach are its feasibleness and its potential to be used by other researchers, tuning it according to their needs, especially if the datasets are made of heterogeneous or incomplete knowledge, and if the goal is to adapt through experimental data. Other --- Discussion --- About this Approach The term "machine learning" was not used in this paper to refer to our solution, which is more appropriately referred to as "statistical learning." We believe the advantages of our approach are its feasibleness and its potential to be used by other researchers, tuning it according to their needs, especially if the datasets are made of heterogeneous or incomplete knowledge, and if the goal is to adapt through experimental data. Other more refined machine learning solutions are more appropriate for other kinds of studies, in which the focus is not on interaction and the learning problem is more complex. This solution has also the advantage of being independent from the implementation and of not being robot-specific. Its limitation is the consequence of such an advantage: if the algorithm is implemented separately, its integration with the robot's environment is also necessary every time. --- Customization The method we proposed can be customized and extended. In the applications described, the following variations were attempted: --- ‚ Class priors left out of the probability formula: alternative solutions are possible, such as a function that biases towards low probability classes using the inverse of the priors, or towards the classes that have been selected fewer times. --- Conclusions An adequate level of cognition is necessary to employ a robot in a human environment. There is a need of representing knowledge, which can be incomplete and heterogeneous, in an effective and efficient way. Adaptation to changing environments can be carried out through different learning techniques, which can be more or less effective depending on the specific problem. This work introduces a quick and effective way of handling this kind of problem adaptation based on statistical learning, specifically on naive Bayes. The method we proposed was applied to two different experiments of human-robot interaction. In the first, the humanoid robot ARMAR-IIIb adapted its greeting behavior from the Japanese to German style, using Japanese sociology data as training. In the second, the robot Nao learned different ways of attracting human users' attention depending on different contexts. In both cases, the adaptation process was successful. The proposed method can be customized and readapted to be used on other robots. Future works include comparison with other machine learning techniques. --- Experiment Results and Validation In this experiment, 18 German people of different ages, gender, workplace, and knowledge of the robot were invited to participate. Some of them participated in a second interaction. At the end, all the feature values had the chance to be classified at least once except for "Location = Private." The number of interactions, including repetitions, was 30: it was determined by the stopping condition of the algorithm. Each time a state, determined by a combination of feature values, had its weights modified during the feedback after each interaction, it is counted as "visited." The count of how many times states have been visited is shown in Table 5. The new mapping of gestures was verified through an objective function V described in the generic Equation , which measures the difference between two different mappings, M1 and M2. V " The function calculates the sum of the variance between the weights w in the same features vector f in two different mappings, M1 and M2. Each variance in the weights is calculated not only by comparing the greeting with maximum likelihood, but also considering the sum of the variances for each greeting j. The function applied to M0J and M1 gives 0.636 as the result. Conversely, comparing M1 with M0G , 0.324 is obtained. The t-test of the variances for each f proves the difference to be significant , validating the hypothesis that M1 would become closer to M0G than to M0J. This result supports the evolution of mapping M1 from M0J towards M0G, assuming that M0G represents German rules correctly: the robot learned a gesture for each social context that is close to the German and more appropriate than the Japanese one. How weights evolve is shown in Tables 6 and7 where on the left the tables are at the starting condition : on the right, variances decrease in Table 6 and increase in Table 7. --- Application 2: Attracting Attention --- Purpose of the Study Socially assistive robots [37] are a category of robots that can actively assist humans thanks to their ability of navigation and their multimodal communication capabilities. However, in order to communicate with a human partner, the robot needs to attract human's attention. Different modalities of communication have been evaluated [38] and compared with multimodal communication cues [39]. The purpose of the present experiment is to explore strategies for successfully initiating communication with humans in a changing environment, making a robot learn which communication channel is more effective for each condition of the room where the interaction occurs. The social robot Nao [40] was used for this application, which was divided in three separate experiments , with different conditions among them. We will examine in detail only the first one. Author Contributions: All authors contributed significantly to the described work. ---

As societies move towards integration of robots, it is important to study how robots can use their cognition in order to choose effectively their actions in a human environment, and possibly adapt to new contexts. When modelling these contextual data, it is common in social robotics to work with data extracted from human sciences such as sociology, anatomy, or anthropology. These heterogeneous data need to be efficiently used in order to make the robot adapt quickly its actions. In this paper we describe a methodology for the use of heterogeneous and incomplete knowledge, through an algorithm based on naive Bayes classifier. The model was successfully applied to two different experiments of human-robot interaction.

‫والدراسات‬ ‫للبحوث‬ ‫ميالف‬ ‫جملة‬ ‫ق‬ . ‫عطية‬ ‫اجمللد‬ 6 ‫العدد‬ 2 47 cultural and economic reflection on the manifestations of traditional social lifestyles of individuals and groups, and their quest to rebuild value models in their new social relationships as a temporary response to the mechanisms of urbanization and integration, this dynamic process that actors in the urban space of the oasis, it opens the door to many questions that we must quickly answer based on the approaches of urban anthropology and symbolic interactive , which has established a deeper dimension in our analysis of the discourse of actors, and researchers, with different ethnic affiliations and multi-ethnic ideological backgrounds , due to the complex strategies of the modern urban fabric practiced by social groups in their possession of desert spaces, in many different central intersections of both local and urban bedouins through their cultural and field discourses. --- Keywords

The totality of the transformations taking place in The City of Ouargla through its implicit manifestations and cultural ramifications, has a clear impact on the structure of extended families as an inevitable product of urban behavior and its

Introduction The ravages of COVID-19 are reflected in the increasing number of daily deaths and infections and in the distortion of residents' mental health, which has become a global public health issue that needs to be intervened in the post-COVID-19 era . Previous studies have confirmed the negative influence of COVID-19 on residents' mental health; for instance, Chen et al. surveyed 18,171 people from 35 countries/societies and found that about 26.6% of the residents had moderate to extreme depressive symptoms, 28.2% of the residents had moderate to severe anxiety symptoms, and 18.3% of the residents had moderate to extreme stress symptoms due to the spread of COVID-19. Later, a follow-up study of 1,161 Americans found that the prevalence of severe depressive symptoms increased from 27.8% in March 2020 to 32.8% in April 2021, and the increase was even more significant among low-income groups . Moreover, from the end of January to the middle of April 2020, the detection rates of anxiety and depression in Chinese samples were 29.6 and 32.5%, respectively, both significantly higher than the levels of pre-epidemic epidemiological surveys . Similarly, other studies [see Rufus et al. , Ramos et al. , and Dyer et al. ] found that the COVID-19 epidemic has significantly increased the rate of mental health disorders, especially among residents in areas with poor economic conditions. Besides, other studies also analyzed the impact of COVID-19 on the mental health of special groups, such as doctors, students, older people, and low-income groups . It is also revealed that the mental health costs of COVID-19 are huge. The large number of mental health cases has strained medical resources, treatment costs, and financial burdens in the era of COVID-19 . Additionally, inefficient work or reduced productivity due to mental health problems created new groups of poor that inhibited the sustainable growth of GDP . Thus, it is found that COVID-19 and its ramifications have caused stress, anxiety, and depression worldwide. In the post-pandemic era, alleviating residents' mental health is significant for coping with new global public health problems and boosting economic and social development. Moreover, much of the literature explored why COVID-19 affects mental health. Firstly, COVID-19 control policies such as wearing masks, restricting travel, keeping social distance, and quarantine policies have changed the way residents live, which may directly impact the mental health of residents through difficulties in breathing fresh air, increase in lonely time, and decrease of human interaction, as well as fear of isolation policy . Secondly, residents, especially those with serious underlying diseases, are worried and afraid that the COVID-19 epidemic is highly contagious and has ambiguous sequelae. No vaccine can prevent 100% of people from getting infected . Thirdly, job insecurity or economic uncertainty due to COVID-19 lockdown and quarantine policies increases residents' stress and anxiety . Fourthly, residents' fear is aggravated by the shortage of medical resources and the concern of cross-infection in the hospitals . Finally, public discrimination against people infected with COVID-19 in employment or social communication is also an essential reason for residents' depression . Consequently, government and social organizations have taken targeted intervention measures, such as providing psychological services, supporting the development of the Internet economy, promoting flexible employment of residents, and timely disclosure of COVID-19 infection information . In addition, several studies have focused on exploring the phenomenon by taking samples of respondents such as doctors, workers in quarantine hotels & airports, and customs inspectors, who are more vulnerable to COVID-19 and are more likely to have serious mental health issues . Therefore, although the influence mechanism of COVID-19 on residents' mental health is more complex, there is a clear causal relationship between them. Further, will this causality break down as COVID-19 containment policies are lifted? Previous empirical studies have not given a clear answer. So, to answer more clearly, the current research will contribute innovatively to the existing body of knowledge. It is further believed that the COVID-19 pandemic has dampened the tourism industry and family tourism consumption due to travel restrictions, quarantine policies for suspected infections, and social distancing. The crash in international tourism due to the coronavirus pandemic also caused a considerable loss of more than $4 trillion to the global GDP for 2020 and 2021, according to a UNCTAD report published on 30 June . Likewise, the study of Martin et al. , using the dynamic CGE modeling framework, also revealed a sharp decline in number of tourists for the year 2020. The study showed that the value of tourism in Tanzania decreased by more than 13%, and total labor demand for tourism and related industries also declined by more than 3.3 percent in 2021. Moreover, COVID-19 has prompted residents to adopt a cautious travel attitude, reduce public transportation use, reduce travel time, lessen international tourism, and prefer outdoor or short-distance travel . Accordingly, the COVID-19 pandemic has significantly reduced the number of tourists and the output value of the tourism industry and related industrial chains. Moreover, it also significantly decreased the ability to absorb employment and severely impacted the development of the tertiary industry and the job market in many countries, especially those that rely on tourism income . Of course, COVID-19 has also accelerated the adjustment of the tourism industry and the market competition pattern, such as digital tourism, innovation in tourism products, and the improvement of tourism services. These changes also provide a good opportunity to recover the tourism industry and consumption after the COVID-19 epidemic . Although the tourism industry is a sunrise industry driven by the spiritual pursuit of residents, some scholars hold that long-distance travel requires a variety of individuals skills, such as physical fitness, concentration, understanding, decision-making, and confidence, and that mental health can affect the acquisition of these skills, which can affect tourists' sense of experience, satisfaction, and happiness . However, other studies have confirmed the unique role of residents' travel consumption in relieving stress, anxiety, or depression . Tourism consumption can improve residents' mental health by contacting the beautiful nature, accepting the improvement of culture, relaxing the body, and forgetting their troubles . Similarly, Liu et al. evaluated the mental health of 89 anxious and 72 depressed tourists and stated that tourism consumption significantly reduces the anxiety of tourists. Based on the literature analysis, Cheng et al. found that tourism consumption can significantly reduce the sense of burnout and pressure of tourists and improve their sleep and mental health. In addition, Sun et al. also argued that tourism consumption has a significant inhibitory effect on family members' negative emotions or mental illness. Besides, some scholars hold a neutral attitude and argue that the causal relationship between tourism and mental health should be interpreted cautiously, as reverse causality may lead to endogenous issues . However, existing studies have not yet considered the role of tourism consumption in the influence of the RCC on residents' mental health. In summary, previous studies have not empirically tested the causal relationship between RRC and residents' mental health. Moreover, the mediating mechanism of family tourism consumption has not been studied previously. To make up for the research gaps, the study's main objects is to innovatively explore the effect of the RCC on residents' mental health and the mediating effect of family tourism consumption. Furtherly, the main contribution include the following: First, we employed the differences-in-differences method to explore the impact of the RCC on residents' mental health using micro-panel data from Shaanxi province, China. Second, considering age and urban-rural differences, this paper explored the heterogeneity of the effects of the RCC. Third, the mediating effect model was used to test the role of family tourism consumption concerning the impact of the RCC on residents' mental health. Finally, the study provides valuable experience for other countries or governments to improve the mental health of residents in the post-epidemic era. --- Literature review and hypotheses development 2.1. Conservation of resources theory Psychologists generally hold that individuals would continuously pursue happiness and success. Individuals are more likely to succeed if they can establish and maintain the personal characteristics and social status that can lead them to higher incomes and protect them from losses . Further, Hobfoll proposed the COR theory, which mainly described the role of resources in the interaction between individuals and the social environment. COR theory limits the concept of resources to material resources , conditional resources , personality traits , and energy resources . The core notion behind this theory is that individuals strive to acquire, maintain, and protect resources they deem valuable. Suppose these resources are at risk of loss because of a stressful event. In that case, individuals prefer to adopt appropriate strategies such as collective action, social support, and optimal allocation of resources to minimize the damage . Therefore, the conservation of resources, loss of resources, and the actions taken result from the individual's stress response. In recent years, COR theory has been used to test stress response and individual coping strategies under the influence of crisis . In the past 3 years, the COVID-19 epidemic and control policies have become the biggest external shocks that individuals face, which may directly reduce resource access opportunities, value-added, and resource allocation efficiency and exacerbates the severity of an individual's mental health. Furthermore, if COVID-19 control policies are relaxed, residents' mental health can improve. Besides, the formation of an individual's mental health is not short-term but the result of the long-term action of underlying risk factors . Individuals would inevitably adopt appropriate family strategies such as family travel consumption to adjust family resource allocation and alleviate long-term mental health problems. Therefore, this paper incorporated the RCC, residents' mental health, and family tourism consumption into the COR theoretical analysis framework. --- RCC and residents' mental health According to COR theory, individuals experience emotional feedback when they perceive the threat of losing resources or experience the actual loss of resources . Welfare economics holds that the most essential resources in the market are the welfare resources owned by individuals and families. Previous studies have described welfare resources mainly from the perspective of family economy, social security, social network, and psychological conditions . If COVID-19 control policies are relaxed, welfare resources can be protected, and increase in value, and mental health problems such as stress, anxiety, or depression caused by residents' fear of resource loss will gradually be lessened; the RCC is suitable for raising residents' family income. In the post-epidemic era, residents can obtain more job opportunities, and wage income growth can become an essential guarantee for improving residents' mental health . Meanwhile, compared to the pandemic, the market potential of household fixed assets preservation and appreciation was better . The RCC can help to enhance the social security of the residents. The stress, anxiety, and depression of residents are mainly due to concerns about social insecurity, such as the epidemic's infection rate and death rate, as well as loneliness due to isolation control and social discrimination against infected people . Third, the RCC could enhance the relationship network of residents. Removing social distancing and isolation policies can lessen the density and intensity of residents' relationship networks. Many studies have further confirmed that the relationship network is crucial for improving mental health concerns . The RCC has significantly enhanced the psychological conditions of residents. Good psychological conditions, such as being respected and confident about the future, are essential to improve residents' mental health . Besides, studies also found that the psychological resilience of older adults with underlying diseases is very weak, and it is difficult for them to get rid of anxiety and depression quickly . Meanwhile, compared with rural areas, cities showed higher population density and frequent mobility, with a higher risk of COVID-19 infection. The epidemic affected residents' economic status and mental health more . Accordingly, the RCC affected urban residents more than those in rural areas. Therefore, we propose the following hypothesis. --- H1: The RCC could significantly improve the mental health of residents H1a: Compared to non-older adults, the RCC had a weak effect on improving mental health in the older adults. H1b: Compared with rural residents, the RCC had a stronger effect on improving the mental health of urban residents. --- The mediating effect of family tourism consumption concerning the impact of the RCC on residents' mental health COR theory holds that individuals are not passive in coping with resource loss and psychological stress but can adjust their strategies according to the resource situation . Family tourism consumption is an essential strategy to optimize the allocation of family resources by improving residents' sense of experience, freedom, and happiness, which can relieve residents' stress, anxiety, and depression caused by COVID-19 . Specifically, first, the RCC enhanced the financial support for family tourism consumption by increasing employment opportunities, unblocking employment channels, and directly improving family income . Second, the RCC abandoned control measures such as social distancing, home restrictions, and hotel isolation to ensure the time and space required for family travel, which became an essential policy condition for developing the tourism industry after the epidemic . Finally, the RCC has stimulated residents' pursuit of a better and more enjoyable life in the past 3 years. Tourism is known as a pastime, enjoyment, and relaxation activity, especially outdoor natural scenery tourism, which could help to improve long-term residents' depressed psychology and negative emotions . Besides, to avoid the causal debate between tourism and mental health, the tourism value theory holds that leisure is the primary function of residents' tourism consumption . To get rid of the hustle and bustle of the city, busy work, and tedious family affairs, residents' travel experience is to change their way of life and experience another kind of beauty in real life . Therefore, we infer that the RCC affected residents' mental health by stimulating family tourism consumption and proposes the following hypothesis. H2: Family tourism consumption had an intermediary effect concerning the RCC's influence on residents' tourism consumption. --- Materials and methods --- Study sites, sampling, and participants The study included the panel data for the two periods, April 1 to 7, 2021, and April 1 to 7, 2023, respectively, through a large-scale online survey of residents from Shaanxi Province, China. The main reasons for the selection of sample areas are as follows: Shaanxi Province is in the west of China, the income gap between urban and rural residents is large, and the differentiation of urban and rural sample areas is obvious. Moreover, the research group won the cooperation with China Mobile Shaanxi Co., LTD. to carry out online questionnaire survey. Specially, firstly, the Mobile Shaanxi Co., LTD. randomly informed residents of the purpose, main content, and rewards for phone calls through mobile phone messages. Secondly, if the respondent agreed, the interviewer contacted them by phone to complete the questionnaire. Finally, the research group protected the transferee's mobile phone number information and collected panel data. The questionnaire's main contents included the respondents' characteristics, the characteristics of their families, their cognitive status, their employment and income, and mental health. Excluding 42 respondents who were unwilling to answer during the second survey, the questionnaire survey obtained data from 735 residents, among which 421 belonged to urban areas while 314 were from rural areas. Besides, since the questionnaire adopted the principle of random sampling and the mobile phone coverage rate of urban and rural residents in Shaanxi exceeded 90%, sample selection bias was minimized. --- Variable selection 3.2.1. Dependent variable In this study, the dependent variable is the residents' mental health. Previous literature has characterized the residents' mental health mainly from stress, anxiety, and depression. Referring to relevant studies such as Zhou et al. and Huang et al. and the time-saving requirements of online questionnaire survey, we selected some representative indicators, such as quality of sleep , feeling sad , concentration at work to measure residents' press; cranky , tachycardia , and fidget to characterize residents' anxiety; hard to do anything , with no hope for life , and suicidal thoughts in head to depict residents' depression. The severity of the mental health issue of the residents was obtained by averaging nine indicators. Cronbach 's alpha was 0.82, signifying these indicators has good reliability. Additionally, "sleep quality" and "concentration at work" were positive indicators, so we conducted a reverse-coding calculation to maintain the same standard measurement as other indicators. Table 1 provides a descriptive statistical analysis of the mental health of the residents. --- Independent variable The independent variable is the relaxation of COVID-19 control policy, categorized by the dummy variable. In December 2022, China relaxed its prevention and control measures and lowered the epidemic from A to B. Meanwhile, the novel coronavirus pneumonia was renamed novel coronavirus infection. Therefore, we assigned a value 1 to samples collected before December 31, 2022, and 0 to samples collected after that date. --- Control variables Referring to the studies of Xiong et al. and Albikawi , the study also included control variables, such as sex, age, education level, risk preference, awareness of COVID-19, the proportion of the older adults and children, job satisfaction, disposable income per capita, time to pay attention to COVID-19, chronic diseases, relationship network, urban or rural areas. Additionally, considering that other policy factors might directly influence the residents' mental health, the study added the influence of government mental health counseling on 2, it is found that there is a significant difference in residents' mental health before and after the RCC. Overall, the mental health level of residents increased by 0.611. The differences in stress, anxiety, and depression between the different groups are-0.990, -0.482, and-0.362, respectively, indicating that the mental health of the residents improved significantly after RCC. In addition, some other control variables also differed considerably between the sample groups. Compared with residents under COVID-19 control, after the COVID-19 control was relaxed, residents had a more precise awareness of COVID-19 , and they could not only realize the harm of COVID-19 but also treat the selflimiting disease objectively and rationally. Residents' job satisfaction is also higher , and per capita disposable income has increased significantly . Moreover, residents have a more robust network of relationships . Further, they have substantially less time to pay attention to COVID-19 and are less likely to receive mental health counseling from the government . --- Empirical methods --- Difference-in-difference method Since the outbreak of COVID-19 in December 2019, the Chinese government has adopted the class A management strategy for class B infectious diseases and implemented various control measures such as maintaining social distancing, wearing masks, and shutting down the infected areas. Until December 2022, the 3-year epidemic has seriously affected the mental health of residents. As the Omicron virus became less virulent, the Chinese government has adjusted and relaxed COVID-19 control. An issue worth studying is whether the mental health of residents is restored after the relaxation of the COVID-19 control policy. What are the possible mediating mechanisms? To this end, first, using the DID model, two periods of panel data from residents of Shaanxi, China, were used to empirically analyze the influence of the RCC on residents' health levels. The model is constructed as follows: Y R CC X it it it i i it = + + + + + α α γ µ ν ε 0 1 Σ Where Y it signifies residents' mental health, including stress, anxiety, and depression. i and t meant county and year. RCC signifies relaxation of COVID-19 control. X it indicates control variables, and Σγ , is the effect of control variables on residents' mental health. α 0 is the constant term and α 1 is the effect of the RCC on residents' mental health. i µ and ν i are locality and time-fixed effect, respectively. ε it signifies the random error term. In addition, since two-term panel data was used, and interviewee were the same individuals at different times. So, we fixed regional and temporal differences, but not individual heterogeneity. --- Mediating effect model Based on model verification , tourism consumption is further added to empirically test that the RCC could significantly improve residents' mental health by improving family tourism consumption. The mediating variable "tourism consumption" is selected mainly given the following considerations: after the deregulation of COVID-19 control, the tourism industry showed retaliatory recovery and development. Meanwhile, travel is also a core mean to improve residents' mental health. Consequently, the study employed the mediating effect model to analyze the mediating effect of tourism consumption. The hierarchical regression is constructed as follows: Y R CC X M R CC X it it it i i it it it it i i = + + + + + = + + + + + α α γ µ ν ε ϕ ϕ γ µ ν ε 0 1 0 1 Σ Σ i it it it it it i i it Y R CC M X = + + + + + + η η η γ µ ν ε 0 1 2 Σ (2 ) Where M signifies mediating variable "tourism consumption, "ϕ 0 and η 0 are constant terms, and ϕ 1 , η 1 , and η 2 are coefficients to be estimated. The meanings of other variables are the same as in formula . The specific testing process of mediating effect is the same as Si et al. . --- Results --- Influence of the RCC on the mental health of residents According to Table 3, it is apparent that the RCC could significantly improve residents' mental health and reduce the severity of mental health issues by 0.602. In particular, the RCC holds a negative inhibitory effect on residents' stress, anxiety, and depression, and the severity of stress, anxiety, and depression decreased by 0.805, 0.406, and 0.315, respectively. Hence, the RCC has shown the strongest negative effect on residents' anxiety, followed by anxiety and depression. Thus, hypothesis H1 is confirmed. Additionally, it is believed that the mental health of the residents is also affected by certain other factors. For instance, the gender of the residents, the awareness of COVID-19, and job satisfaction are also likely to significantly and negatively influence the mental health of the residents. If the residents surveyed were men, their mental health severity would decrease by 0.206; If residents realized the harmfulness of COVID-19 and the self-limiting nature of the virus, their mental health severity would decrease by 0.406; If the residents' job satisfaction increased by 1 unit, the severity of the residents' mental health would decrease by 0.505. Meanwhile, per capita disposable income, relationship networks, and mental health counseling also negatively influenced residents' mental health. If per capita disposable income is increased by 1 unit, their mental health severity would decrease by 0.206; if the relationship network is increased by 1 unit, their mental health severity would decrease by 0.208. Furthermore, if residents received mental health counseling from the government, the severity of their mental health would be reduced by 0.031. Additionally, some other factors could exacerbate residents' mental health seriousness. If the proportion of the older adults and children and the time to pay attention to COVID-19 increases by 1 unit, the severity of the mental health of the residents would increase by 0.291 and 0.038, respectively. The DID method required that there was no significant difference in residents' mental health before December 31, 2022, between the treatment group and the control group . According to Figure 1, it is found that there is no significant difference in residents' mental health before December 31, 2022, while the severity of residents' mental health decreased significantly during January-March 2023, which further verifies the positive promotion effect of the RCC on improving residents' mental health. --- Placebo test Further, exploring whether the estimation results of the DID method are biased or not due to missing variables, this paper conducted a placebo test through a randomized selection of treatment groups. Since the newly generated treatment group was random and would not affect the explained variable, its estimated coefficient should be around 0. This paper repeated the random generation process 1,000 times and reported the estimated coefficient of the random treatment group and its p-value distribution in Figure 2. The results showed that the average estimation coefficient of the randomly generated treatment group is-0.0003, which is near 0 and far away from-0.602 in Table 3, indicating that there is no obvious model estimation bias issue. 4,5 showed the influence of the RCC on the mental health of residents of different ages and regions, respectively. Specifically, on the one hand, the RCC did not significantly influence the mental health of residents over the age of 60; that is, the mental health of residents over the age of 60 has not improved considerably after the RCC. However, the RCC showed a linear significant effect on the mental health of residents under 60 years; that is, with the gradual increase of age, the RCC holds a stronger inhibitory effect on the severity of the mental health of residents. Thus, hypothesis H1a is confirmed. On the other hand, the RCC also showed significant effects on the mental health of residents belonging to urban and rural areas. Still, its improvement effect on the severity of the mental health of urban residents is greater than that of rural residents. Thus, hypothesis H1 b is also confirmed . --- Testing the mediating effect of tourism consumption This study also used the mediating effect model to verify the mediating mechanism of tourism consumption related to the RCC that influences the mental health of residents. The study selected "amount of family tourism consumption in the first quarter " to measure mediating variable "tourism consumption. " Using the hierarchical regression model, the results showed that the RCC positively affects tourism consumption. Meanwhile, the RCC and tourism consumption significantly influenced residents' mental health. The intermediary effect of tourism consumption is 0.1492 , and its proportion in the total effect is 0.2458 . Therefore, 24.58% of the inhibitory effect of the RCC on residents' mental health severity is found to be contributed by family tourism consumption. Thus, hypothesis H2 is also endorsed. --- Discussion In infectious disease prevention and control, humanity has experienced the longest, largest, and most damaging COVID-19 outbreak . Against climate change, financial turmoil, food crisis, and public health crisis, the COVID-19 pandemic has exacerbated negative impacts on industrial development, international trade, labor employment, and mental health . This paper focuses mainly on answering the previous discussion in academia; that is, since the COVID-19 epidemic has caused severe damage to residents' mental health, will residents' mental health improve after relaxing the control policy of the COVID-19 epidemic? Meanwhile, we discuss the possible mechanism or reason from the perspective of family tourism consumption, unlike many previous studies that only studied the influence of COVID-19 on one aspect, such as the enterprise supply chain, food import and export, household production decisions, and the mental health of residents . However, the current study explores the link between RCC, family tourism consumption, and the mental health of residents, which could provide a more plausible explanation for the knock-on effects of COVID-19. Unlike the study of Wilding et al. , Razali et al. , and Hecker et al. studies, which focused on the direct causal relationship between COVID-19 and residents' mental health, our research innovatively and empirically confirms the promotion role of the RCC in improving residents' mental health. Firstly, the RCC has canceled the home restriction and isolation control policy , so that residents can have free activities and seek the best comfortable environment. Second, the RCC accelerates the resumption of business and production, provides adequate employment opportunities , and eases the pressure and anxiety of increased family life security and income. Third, the protective antibodies produced by the vaccine and the in-depth understanding of the novel coronavirus have made residents less fearful, and reduced their worries and depression about infection and fear of death . Finally, the RCC significantly improves the residents' face-to-face communication, enhances the strength of the relationship network, and relieves residents' anxiety and depression . In addition, considering the differences in the ages and regions of the residents, we further analyzed the heterogeneity of the impact of the RCC on the mental health of residents. Although many previous studies have confirmed a causal relationship between the COVID-19 pandemic and mental health in the older adults people , our study reported insignificant improvement in the severity of mental health in residents over 60 years old after the COVID-19 pandemic was relaxed. Old-age residents are vulnerable to COVID-19, accounting for a high proportion of severe cases and deaths . Meanwhile, they also suffer from underlying diseases such as diabetes, asthma, heart or brain infarction, etc. . Therefore, given the alternate peaks of COVID-19, the previous mental states of stress, anxiety, and depression are not changed. Moreover, our study confirmed the negative linear inhibitory effect of the RCC on the mental health severity of residents. This is mainly due to easing employment pressure and increasing household income after the COVID-19 control was eliminated . Besides, we also find that the RCC improved the mental health of urban residents more than rural residents. Rural residents have apparent advantages over urban residents in terms of the impact of COVID-19 on labor transfer, living security, and epidemic prevention pressure. Thus, they have lower levels of mental health Test results of equilibrium trend. We also explored the impact of other factors on the mental health of residents. Consistent with the studies of Xiong et al. and Wall and Dempsey , our study also confirmed that women's mental health is more serious than men's; the RCC has a stronger effect on the mental health of male residents. Awareness of COVID-19 helps improve residents' behavioral decisions about vaccination and production investment but also affects residents' mental health . Our study also showed that the higher the awareness of COVID-19, the lower the severity of stress and anxiety. Furthermore, our findings are supported by Abd-Ellatif et al. and Cheng and Kao , who hold that COVID-19 has changed job opportunities, employment environment & income, and decreased residents' job satisfaction significantly. Furthermore, such negative satisfaction directly aggravates residents' mental health severity. In addition, it is also found that other factors also exacerbate the seriousness of the mental health of residents. The older adults and children are vulnerable to COVID-19 because they have weak immunity . If the older adults and children account for a relatively high proportion of the family population, the stronger the residents' attention to their health, the more serious the negative emotions of stress and anxiety . Of course, residents' mental health issues are also closely related to their daily life habits. For example, the longer they pay attention to COVID-19, the more they may become too sensitive to the novel coronavirus and self-protection, eventually aggravating their mental health. Finally, consistent with the studies of Gilbert and Abdullah , Chen et al. , and Dillette et al. , we also find the mediating effect of tourism consumption on improving residents' mental health influenced by RCC. Firstly, the RCC has changed travel restrictions or quarantine policies due to COVID-19, providing the necessary conditions for the recovery of the tourism industry . Secondly, tourism consumption improves residents' sense of experience and happiness, which can significantly improve the stress, anxiety, and depression caused by COVID-19 . Thirdly, tourism consumption improves residents' social interaction and relationship networks, opens channels for residents to express their emotions and objects to express their emotions, and can reduce mental health problems caused by COVID-19 . Finally, studies also confirmed that tourism consumption could repair the long-term impact of COVID-19 on residents' mental health by adjusting their lifestyles, improving their environment, and communicating with nature . Of course, our research still has some shortcomings. For example, the RCC data was only available for 3 months, and the study only explored the short-term effects of the RCC on the mental health of the residents. Therefore, the long-term effect of the RCC on residents' mental health needs further investigation. Moreover, some unobserved factors may also affect both the RCC and the mental health of residents, thus generating endogenous issues, which need to be further solved by obtaining survey variables and data. Besides, due to using the panel data of two periods for Shaanxi province, China, we do not have enough data points to test whether there was a pre-trend before the RCC lift. --- Conclusion and policy implications In the post-epidemic era, in addition to tracking the mutation of the novel coronavirus, designing targeted vaccines, and developing effective drugs, the residents' mental health also deserves the international community's attention. The RCC will inevitably lead to economic and social development recovery, but the residents' mental health resilience is very weak. Whether mental health can recover effectively from RCC also needs theoretical and empirical exploration. In this paper, the panel data of Shaanxi, China, were used to analyze the effects of the RCC on residents' mental health and the intermediary mechanism of tourism consumption, respectively, by employing the DID method and the mediating effect model. The following conclusions are drawn. Firstly, the RCC significantly inhibited the mental health severity of residents, and the mental health severity decreased by 0.602. In particular, the RCC has a negative and significant influence on residents' stress, anxiety, and depression, and the severity of stress, anxiety, and depression decreases by 0.805,0.406, and 0.315, respectively. Hence, the RCC has the strongest negative effect on residents' stress, followed by anxiety and depression. Secondly, the gender of the residents, awareness of COVID-19, job satisfaction, per capita disposable income, relationship network, and mental health counseling also significantly and negatively influence the seriousness of mental health. However, the proportion of older adults and children and the time to pay attention to COVID-19 can exacerbate the severity of mental health. Thirdly, the RCC's effects on residents' mental health are heterogeneous. The RCC had a linear significant effect on the mental health of residents under 60 years, while it does not significantly influence the mental health of residents over 60 years. Meanwhile, the RCC's improvement effect on the mental health severity of urban residents is greater than that of rural residents. Finally, tourism consumption plays a mediating role in the RCC's influence on residents' mental health. The intermediary effect of tourism consumption is 0.1492 , and its proportion in the total effect is 0.2458 . In the post-epidemic era, it is necessary to strengthen mental health interventions. Firstly, the government should strengthen residents' mental health identification and treatment. Community and public hospitals should increase the number of mental health clinics, expand the scope of identifying residents' mental health issues, and initiate early intervention strategies. Meanwhile, the government should also improve access to mental health counseling through online consultation platforms, provide mental health relief and self-help information to residents, and help them improve their stress, anxiety, --- Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- --- --- Publisher's note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Objective: COVID-19 has negatively influenced industrial development, family consumption, and residents' mental health. Unfortunately, it has not yet been studied whether this adverse situation can be alleviated after the relaxation of the COVID-19 control policy (RCC). Therefore, this study aimed to analyze the effect of the RCC on the resident's mental health and the mediating effect of family tourism consumption. Methods: By using the PSM and mediating effetc model to research the panel data of two periods (April 2021 and April 2023) for Shaanxi province, China.The RCC negatively inhibited the mental health severity of residents, and the mental health severity decreased by 0.602. In particular, the RCC showed the most substantial negative effect on residents' stress, followed by anxiety and depression. Meanwhile, it is found that the impact of the RCC on the mental health of residents is highly heterogeneous. The RCC indicates a linear significant effect on the mental health of residents under 60 years of age, while the results were found insignificant for residents above 60 years of age. Meanwhile, the RCC's improvement effect on urban residents' mental health is greater than that of rural residents. In addition, mechanism analysis showed that tourism consumption plays a mediating role in the influence of the RCC on the mental health of residents, and the mediating effect accounted for 24.58% of the total effect.Based on the findings, the study proposes that government and policymakers should strengthen mental health intervention, improve access to mental health counseling, stimulate economic development, expand the employment of residents, and track the mutation of the novel coronavirus.

Introduction With the intensification of global climate change and geophysical movements since the beginning of the 21st century, earthquakes, tsunamis, landslides, mudslides, and other disasters have occurred frequently, profoundly influencing global economic and social development. Of these disasters, earthquakes are the most catastrophic, and thus, disaster-risk management for earthquakes has become a hot spot in academic and political circles [1,2]. According to Emergency Events Database , from 2000 to 2018, 87,877 people were killed and 8,303,867 people were affected by earthquakes worldwide [3]. China is a mountainous country with frequent earthquake disasters [4][5][6][7]. According to statistics, from 2000 to 2017, there were 179 earthquakes with a magnitude of 5 or above in China, resulting in 488,437 casualties and direct economic losses of 1,133,424.9 million Yuan [8]. As the world's most famous earthquake province, Sichuan is the province with the most serious earthquake disasters in China. From 2000 to 2017, there were 18 earthquakes with a magnitude of 5 or above in Sichuan, leading to 459,993 casualties and direct economic losses of 938,710.93 million Yuan. Among them, the 5•12 Wenchuan Earthquake in 2008, the 4•20 Lushan Earthquake in 2013, and the 8•8 Jiuzhaigou Earthquake in 2017 were great earthquakes with a magnitude of 7 or above, causing 459,863 casualties and direct economic losses of 932,005.43 million Yuan [8]. The construction of a resilient disaster-prevention system in earthquake-prone residential areas has become a focus for government and academic circles. In general, however, academic studies of earthquake disaster-risk management are concentrated in developed countries , with insufficient attention given to the disaster-risk management of residents in earthquake-prone areas in China. In particular, studies of the disaster-risk management of rural households in mountainous settlements where earthquakes are extremely serious are relatively few. In China, due to the influence of geology and resource endowment, the settlements in mountain areas are not only disaster-prone areas, but also poverty concentrated areas. It is of great significance to pay attention to the disaster risk management of such groups, especially the risk response to the earthquake. Additionally, in the few researches on disaster risk management in earthquake-stricken areas in China, scholars pay attention to different contents due to different perspectives. For example, Cui et al. [13] mainly explores the construction of resilience and disaster prevention system at the community scale, Han et al. [14] mainly focuses on the impact of households with or without disabled members on their disaster preparedness. In general, few studies have focused on the correlation between financial preparedness and disaster risk perception from the perspective of rural household financial preparedness. Therefore, there is an urgent need to carry out such research [2,15]. Many empirical studies have shown that residents' disaster preparedness is key to their coping with the impact of disasters [16][17][18][19]. However, the existing academic research mostly measures residents' disaster preparedness from the perspective of ensuring the physical safety of residents. For example, residents are asked whether they have emergency supplies , whether they have an escape plan, and whether they have purchased disaster-related insurance . However, in the face of earthquakes, which are highly catastrophic, such simple disaster preparedness as the preparation of an emergency kit can only guarantee the safety of residents to a certain extent and is of limited help in restoring and reconstructing communities after the devastation of an earthquake. In the face of earthquake disasters, national relief, social assistance, and catastrophe insurance can help residents carry out post-disaster reconstruction to some extent. However, from the three earthquakes with a magnitude of 7 or above in Sichuan in recent years, it can be seen that, compared with the direct losses caused by the disasters, external financial assistance was limited [15] and catastrophe insurance was not implemented. Thus, in the case of limited external relief funds, the post-disaster reconstruction of residents in earthquake-stricken areas had to rely on their own coping ability-namely, their financial preparation. Despite this fact, few academic quantitative studies have measured and explored the size and characteristics of residents' financial preparation in earthquake-prone areas, thus, it is urgent to carry out this research [15]. Although the study on the characteristics of residents' financial preparation in a small area has no obvious correlation with the residents' financial preparation in the earthquake threatened area under other social and cultural backgrounds; however, the measure of financial preparation of rural households in earthquake-stricken areas in this study can provide useful enlightenment for disaster risk management in earthquake-threatened areas under other cultural backgrounds, and even make a comparative study of cross-regional and cross-cultural backgrounds. Meanwhile, China is a large earthquake country, and the earthquake sample region selected in this study is its typical representative region. Understanding the characteristics of rural households' financial preparation in this region can provide certain reference basis for the implementation of financial preparation policies of rural households in other areas threatened by earthquake disasters in China. Facing the threat of earthquake disasters, rural households will take corresponding actions only when they perceive the risks [6,21]. Therefore, the disaster-risk perception of residents in disaster-prone areas and the influencing factors have always been the focus of academic research. The research by Lindell [18], Bubeck et al. [22], Huang et al. [23], Lindell and Perry [24], and Solberg et al. [25] has systematically reviewed residents' disaster-risk perception and the driving factors as well as the correlations between disaster-risk perception and disaster-avoidance decisions. In the existing research, residents' individual and family socio-economic characteristics and disaster experiences are commonly used indicators. However, due to the differences in disaster types and regional socio-economic culture, the results of the correlations between these factors and residents' disaster-risk perception are not uniform [22,24]. For instance, Lawrence et al. [26] have found that flood disaster experience can improve residents' disaster-risk perception, and Xu et al. [21] have discovered that landslide disaster experience can enhance residents' perception of the possibility of disaster occurrence but has no significant influence on the perception of threat and controllability of disaster occurrence. For earthquakes, which are especially serious as soon as they occur, how do residents' socio-economic characteristics and disaster experience affect their disaster-risk perception? What are the correlations between financial preparation, which is an effective means for residents to cope with the impact of earthquake disasters, and disaster-risk perception? In the above context, this study takes as its object rural households from areas stricken by the 5•12 Wenchuan Earthquake and the 4•20 Lushan Earthquake in Sichuan province and explores the construction of an index system for rural households' financial preparation from the perspective of the internal-and external-coping abilities of these households. Moreover, it uses statistical models to explore the correlations between rural households' financial preparation or earthquake disaster experience and disaster-risk perception. This study intends to solve the following two scientific problems: What are the characteristics of the financial preparation, disaster experience, and disaster-risk perception of rural households in earthquake-prone areas? What are the correlations between rural households' financial preparation or disaster experience and disaster-risk perception in earthquake-prone areas? --- Theoretical Development The disaster-risk perception of residents in disaster-prone areas and the influencing factors have always been the focus of academic research. Scholars have conducted a lot of explorations on the correlations between residents' individual and family socio-economic characteristics, disaster experience or disaster preparedness, and disaster-risk perception in different threat areas of different disasters, obtaining inconsistent results [27]. This study focuses on the correlations between residents' financial preparation, disaster experience, and disaster-risk perception in earthquake-stricken areas in Sichuan. --- Rural Households' Financial Preparation and Disaster Risk Perception According to existing studies, residents in disaster-stricken areas may experience the phenomenon of "survivor bias", which means families with good financial preparation may underestimate the probability or impact of a disaster [15,22]. Therefore, families with financial preparation, such as residents with a high income diversity index, high income, high asset availability, deposits, and commercial insurance, generally believe that even if a major earthquake were to occur, they can reduce the impact of the disaster on their family by relying on the internal-coping ability of their family. For this reason, their perception of the severity of disaster occurrence is relatively low. For example, Lo and Cheung [15] have found that residents who purchase insurance have a relatively low perception of the severity of earthquakes. Miceli et al. [20] have discovered that residents' disaster-preparedness behavior is not significantly correlated with the probability of their risk perception of flood disaster occurrence, but it is significantly positively related to the severity of flood disaster occurrence. Xu et al. [19] have realized that residents' insurance purchase behavior is significantly positively correlated with the threat and possibility of landslide disasters. Helweg-Larsen [28], Paton and Johnston [29] have found that individuals with disaster preparedness perceive a lower need for additional preparedness than other people. Meanwhile, many empirical studies on disaster risk management show that the strength of residents' social network also has an important impact on their risk perception and disaster preparedness [30][31][32]. Among them, in the face of the earthquake disaster, whether residents can smoothly borrow money from friends and relatives and borrow money from banks is an important sign of their social network. According to relevant researches in the field of sustainable livelihood , rural households are faced with strong external shocks , when their internal-coping capacity is insufficient to cope with the losses caused by the earthquake to their families, external-coping capacity will come into play. Therefore, for families with different social networks, their disaster risk perception may present different states. For example, Lo and Cheung [15] have found that access to commercial credit is significantly positively correlated with the possibility of disaster occurrence. However, generally speaking, the maintenance of social network needs costs, thus, rural households will not easily use social network. Rural households only use them when they feel a strong threat and their internal-coping capacity is insufficient to cope with the threat. Therefore, the occurrence of severity perception and social network may be positively correlated. Based on this, research hypothesis H1 was proposed. Hypothesis 1 . Rural households' financial preparation is significantly correlated with disaster-risk perception. Specifically: Hypothesis 1a . Rural households' internal-coping ability is significantly positively related to the possibility of disaster occurrence, and is significantly negatively related to the severity of disaster occurrence. --- Hypothesis 1b . Rural households' external-coping ability is significantly negatively correlated with the possibility of disaster occurrence, and is significantly positively correlated with the severity of disaster occurrence. --- Residents' Disaster Experience and Risk Perception Residents' disaster experience is often regarded as one of the important factors affecting risk perception. Although the measurement of residents' disaster experience is not uniform [33,34], most empirical research results show that residents' disaster experience is positively significantly correlated with their disaster risk perception. For example, Xu et al. [6,19] have used whether residents have landslide disaster experience to carry out the measurement, and have found that there are positive correlations between disaster experience and the possibility and severity of disasters. Lo and Cheung [15] have adopted the severity of residents' disaster experience to carry out the measurement, and have found similar results. Based on this, research hypothesis H2 was proposed. Hypothesis 2 . Rural households' disaster-experience severity is significantly correlated with disaster-risk perception. Specifically: Hypothesis 2a . Rural households' disaster-experience severity is significantly positively related to the possibility of disaster occurrence. --- Hypothesis 2b . Rural households' disaster-experience severity is significantly positively related to the severity of disaster occurrence. --- Data and Methods --- Data Source The data used in this study are mainly from the questionnaire survey conducted by the research team in the areas stricken by the Wenchuan Earthquake and the Lushan Earthquake in July 2019, and the survey method is a one-on-one face-to-face interview. The contents of the survey mainly include rural households' sustainable livelihoods, residents' disaster-risk perception, residents' disaster-avoidance behavior, the construction of a resilient disaster-prevention system in villages, etc. The time for each questionnaire was about one and a half hours. Some objective indicators, such as rural households' income, were mainly adopted to inquire about the family situation of rural households by the end of 2018, whereas some subjective indicators, such as residents' disaster-risk perception, were primarily used to ask about the status of respondents when they were surveyed. In order to ensure the typicality and representativeness of the selected samples, this study chiefly adopted the stratified sampling method, which is a probability sampling technique, to determine the survey samples. The specific operation process was as follows: Firstly, with regard to the selection of sample counties, this study was mainly based on the following two aspects: 1. The four sample counties should be from the areas stricken by the Wenchuan Earthquake and the Lushan Earthquake . 2. There are significant differences in economic development level between the two sample counties selected for each of the two major earthquakes. Based on the above considerations, this study selected as sample counties Beichuan County and Pengzhou City from 10 counties stricken by the Wenchuan Earthquake , and Baoxing County and Lushan County from six areas stricken by the Lushan Earthquake. Secondly, after sample counties were selected, two sample townships were randomly selected from each sample county according to differences in the level of economic development within the counties and the distance from the county center and the serious-disaster situation, especially the number of threatened people. A total of eight townships were obtained. Thirdly, after the sample townships were determined, the villages in each sample township were divided into two types in accordance with the number of threatened people in the villages, the differences in the level of economic development, the distance from the township center, and other indicators; one village was randomly selected from each type of village as the sample village. In this way, a total of 16 villages were obtained. Fourthly, concerning the determination of sample rural households, after the sample villages were determined, the front-line team members obtained the roster of rural households in the sample villages from village cadres, and 20-23 rural households were randomly selected from each sample village as sample rural households according to the pre-set random numerical tables. Finally, in order to obtain high quality survey data, unify the questionnaire answer standard and teach the basic etiquette and skills of interview research, the teachers of the research group systematically trained 13 researchers who participated in the survey within one day; then, 13 researchers who received strict training conducted one-on-one face-to-face interviews in the homes of rural households under the guidance of village cadres, and a total of 327 valid questionnaires were obtained from 16 villages of eight townships in four counties. --- Methods --- Selection and Definition of Model Variables The objective of this study was to probe the correlations between rural households' financial preparation, disaster experience, and disaster-risk perception. Rural households' disaster-risk perception was the dependent variable of this study. With regard to the measurement of disaster-risk perception, in academic circles there are two main schools; namely, the cultural theory school and the psychological measurement paradigm . Consistent with the research by Xu et al. [2], Armas [9], Xu et al. [21], Solberg et al. [25], Lindell and Whitney [35], Lo [36], Slovic [37], and Sun and Han [38], this study argued that disaster-risk perception is a measurable multi-dimensional concept. Based on this, this study mainly designed entries from the two dimensions of possibility and severity of earthquake disaster occurrence to measure disaster-risk perception, and the specific measurement entries are detailed in Table 1. Before the measurement, an internal consistency test was carried out on the entries, characterizing residents' disaster-risk perception. Cronbach α values corresponding to the probability of disaster occurrence, the severity of disaster occurrence, and the perception of disaster risks were 0.70, 0.64, and 0.72, respectively, which are all greater than 0.60, indicating that the entries designed by this study had good internal consistency. Subsequently, this study used factor analysis to reduce the dimensionality of the entry of disaster-risk perception, so as to obtain the two dimensions of the probability and severity of disaster occurrence. The value of Kaiser-Meyer-Olkin corresponding to factor analysis is 0.74, and the cumulative variance contribution rate of the two dimensions is 61.92%, which indicates that the results of the factor analysis are reasonable . Rural households' financial preparation is one of the two core independent variables of this study. It relates to rural households' income, family assets, or borrowing capacity. Based on this, referring to the setting of residents' financial preparation in the research by Armas [9], Becker et al. [10], Lo and Cheung [15], Bubeck et al. [22], Keil et al. [39], Le Dang et al. [40], and Paul and Bhuiyan [41], this study mainly measured rural households' financial preparation from two dimensions, which are the internal-coping ability and external-coping ability. Rural households' internal-coping ability is characterized by total family cash income, income diversity, whether rural households have deposits, current asset diversity, and whether rural households purchase commercial insurance. Rural households' external-coping ability is characterized by whether rural households can borrow sufficient money from formal institutions and whether they can successfully borrow money from informal channels when a catastrophe such as an earthquake occurs. Income diversity is measured by dividing the main income source channels of rural households by the total channels of income sources. The total channels of income sources mainly consist of five aspects: agricultural income, wage income, business income, income from relatives and friends, and transfer payment income , and the main income source channels of rural households are generally one or more of these five aspects. Current asset diversity is measured by dividing the present value of current assets by the present value of total family assets. The present value of current assets refers to the present value of valuable fixed assets owned by rural households, other than houses, while the present value of total family assets represent the present value of current assets as well as the present value of rural households' housing assets. Rural households' disaster experience is the other core independent variable of this study. Mainly referring to the setting in the research by Lo and Cheung [15], this study adopts the severity of rural households' earthquake disaster experience to measure rural households' disaster experience. In order to minimize the impact on the independent variables of missing important variables, this study, with reference to the research by Xu et al. [21], Bubeck et al. [22], Lindell and Perry [24], Lo [42], Lindell and Hwang [43], Sun and Sun [27], Yu et al. [44], Lindell and Perry [45], Lazo et al. [46], and Peng et al. [47,48], also includes some variables that may affect residents' disaster-risk perception as control variables, mainly each respondent's age, gender, years of education, occupation, residence time, nationality, etc. --- The Models Since the probability of disaster occurrence and the severity of disaster occurrence, which are the dependent variables of this study, are interval variables, this study used ordinary least square to estimate the models when exploring the correlations between rural households' financial preparation or disaster experience and disaster-risk perception. The simple expression of the model is as follows: Y i = α 0 + β 1i × FP i + β 2i × Experience i + β 3i × Control i + ε i where Y i refers to the dependent variable of the model, which can be decomposed into two indicators, namely Possibility and Severity; FP i , Experience i , and Control i represent rural households' financial preparation, disaster experience severity, and control variable, respectively; α 0 , β 1i , β 2i , and β 3i represent the model parameters to be estimated, respectively; and ε i represents the residual term. Stata 11.0 was adopted in the whole model implementation process. --- Results --- Descriptive Statistics of the Variables Table 3 shows descriptive statistics of the variables in the model. As for financial preparation, in terms of rural households' internal-coping ability, rural households' income diversity index was 0.5 on average, indicating that rural households have an average of 2-3 main income sources. The average annual family cash income is 66,238.94 Yuan, which showed great fluctuation. Among 327 sample rural households, 46% of them had deposits, and 28% of them had purchased commercial insurance. Lastly, rural households' asset diversity index was 0.15 on average, indicating that rural households' family assets were more allocated to real estate. With regard to rural households' external-coping ability, whenever there was a catastrophe such as an earthquake, 69% and 75% of rural households could borrow money from banks and borrow money from friends and relatives, respectively. Concerning the severity of residents' disaster experience, 89.60% of rural households believed that their disaster experience was serious. Regarding control variables, 46% of the respondents were women; the average age of the respondents was 53.44; the average years of education was 6.29; the average residence time at home was 41.71 years; 82% of the respondents were Han people; and 57% of rural households were farmers. --- Model Results Tables 4 and5 show the correlation coefficient matrix and regression analysis results of model variables, respectively. As shown in Table 4, the correlation coefficients among all variables of the models are below 0.8, which indicates that there is no serious multi-collinearity between the independent variables of the models. As shown in Table 5, Model 1, Model 2, and Model 3 are the results when the probability of disaster occurrence is taken as the dependent variable. Model 1 is the result of only including rural households' financial preparation, and Model 2 is the result of only including the severity of disaster experience, while Model 3 is the result of including control variables based on Model 1 and Model 2. The results of Model 4, Model 5, and Model 6 are similar to those of Model 1, Model 2, and Model 3, except that the dependent variable of the models is the severity of disaster occurrence. From all the model test statistics , it is seen that the results of all models, except Model 2, are significant at the level of 0.1 and above, and R-squared values corresponding to Model 3 and Model 6 are 0.113 and 0.107, respectively, suggesting that independent variables can, respectively, explain 11.3% and 10.7% of the probability of disaster occurrence. As for the correlations between financial preparation and possibility in Model 1 and Model 3, rural households' total family cash income, asset diversity, and whether rural households can borrow money from relatives and friends whenever there is a catastrophe such as an earthquake were significantly negatively correlated with the probability of disaster occurrence . In other words, if rural households' total family cash income is more, the proportion of the present value of current fixed assets in the present value of total family assets is larger, and rural households can borrow money from relatives and friends whenever there is a catastrophe such as an earthquake, rural households will believe that the probability of an earthquake will be smaller. Specifically, when other conditions remain unchanged, with every one unit increase in the logarithm of rural households' total cash income, rural households' perception of the probability of a disaster will decrease, on average, by 0.113 units. Furthermore, with every one unit increase in the proportion of the present value of current fixed assets in the present value of total family assets, rural households' perception of the probability of disaster occurrence will decrease, on average, by 0.908 units. Lastly, compared with rural households who cannot borrow money from relatives and friends whenever there is a catastrophe such as an earthquake, rural households who can borrow money from relatives and friends in those circumstances will believe that the probability of a disaster will decrease, on average, by 0.292 units . Meanwhile, it is noted that among the seven indicators of rural households' financial preparation, four indicators were not significantly related to the possibility of disaster occurrence. The correlation coefficient between the severity of residents' disaster experience and the possibility of a disaster is positive but not remarkable. In addition, all control variables were not significantly correlated with the probability of disaster occurrence. As for the correlations between financial preparation and severity in Model 4 and Model 6, asset diversity and whether rural households can borrow money from banks whenever there is a catastrophe such as an earthquake were significantly positively related to the severity of the disaster. In other words, if the proportion of the present value of rural households' current fixed assets in the present value of total family assets was larger, and rural households can borrow money from banks whenever there is a catastrophe such as an earthquake, rural households will believe that the severity of the earthquake will be stronger. To be specific, when other conditions remain unchanged, with every one unit increase in the proportion of the present value of rural households' current fixed assets in the present value of total family assets, rural households' perception of the severity of disaster occurrence will increase, on average, by 0.918 units. Compared with rural households who cannot borrow money from banks, whenever there is a catastrophe such as an earthquake, rural households who can borrow money from banks in those circumstances will believe that the severity of the disaster will increase, on average, by 0.245 units . It is noted that among the seven indicators of rural households' financial preparation, five indicators are not significantly correlated with the severity of the disaster. If rural households' earthquake disaster experience is more severe, their perception of the severity of the disaster will be stronger. Specifically, when other conditions remain unchanged, with every one unit increase in the severity of rural households' earthquake disaster experience, rural households' perception of the severity of the disaster will increase, on average, by 0.306 units . Additionally, all control variables were not significantly related to the severity of the disaster. Note: *** p < 0.01, ** p < 0.05, * p < 0.1. 1-14, respectively, represent an income diversity-occupation; among them, 1-5 belong to internal-coping ability, while 6 and 7 belong to external-coping ability. --- Discussion Rural households' disaster preparedness is an important part of the construction of a regionally resilient disaster-prevention system, and financial preparation is the most important part of disaster preparedness, directly relating to the extent to which rural households can carry out post-disaster reconstruction. However, few studies have focused on the financial preparation of rural households in disaster preparedness, the measurement and characteristics of financial preparation of rural households in earthquake-stricken areas, and the correlation between financial preparation and disaster risk perception. The marginal contribution of this study was to make up for the above deficiencies. Specifically, this study constructed an index system for rural households' financial preparation from the perspective of rural households' internal-coping ability and external-coping ability; using survey data of rural households in the areas stricken by the Wenchuan Earthquake and the Lushan Earthquake, this study empirically analyzes the correlations between rural households' financial preparation or disaster-experience severity and disaster-risk perception. The construction of a financial preparation index system and the results of the empirical research in this study can provide enlightenment for the construction of a resilient disaster-prevention system in earthquake-prone areas. Meanwhile, the measurement of financial preparation in this study can also provide useful enlightenment for other similar researches. The internal-coping ability of rural households is an important factor affecting their disaster risk perception. Inconsistent with hypothesis H1a, this study found that income diversity, total cash income, whether rural households had deposits, and whether rural households purchased commercial insurance were not significantly correlated with residents' disaster risk perception. At the same time, it is interesting that the correlation between asset diversity and the probability and severity of disasters turned out to be the opposite of research hypothesis H1a. The possible reasons for the results are as follows. The research area of this study is mostly hilly. Influenced by geographical location and natural resource endowment, rural households' agricultural income or business income is not high. At the same time, with limited years of education and few skills, most migrant workers are engaged in construction and service industries, and their wages are relatively low. In the face of the impact of education, medical treatment of serious diseases, human relations, and other large expenditures, rural households' annual cash income is not much. Therefore, deposits are relatively limited, and are generally insufficient to deal with the impact of earthquakes and other catastrophes on families. Meanwhile, there is no earthquake catastrophe insurance in the study area. While many rural households have purchased commercial insurance, this insurance is mostly used for old-age care or medical treatment for serious diseases, and thus, has little impact on rural households' resistance to earthquakes. In addition, due to the expense of children's marriages or competition with others in the village, who are also on a relatively low income, many rural residents in China generally invest the money they have saved over the years in fixed assets, especially housing [5]. Therefore, in this study, the asset diversity index is markedly correlated with residents' disaster-risk perception. It is also noted that although many studies on sustainable livelihoods of rural households have shown that rural households can sell their fixed household assets to withstand external shocks . However, earthquake shock is different from other risk shocks . If the earthquake shock is strong, it will directly threaten the lives and fixed assets of rural households. In this case, it will be difficult for rural households to sell their fixed assets to withstand the earthquake. At this time, rural households may have more survivor bias [15,22]. For the safety of life and assets, they will underestimate the possibility of disasters and overestimate the severity of disasters. Therefore, in this study, asset diversity is negatively significantly correlated with the probability of disaster occurrence, and positively significantly correlated with the severity of disaster occurrence. In the face of external risk impact, when the internal-coping capacity of rural households is insufficient, their external-coping capacity will play a crucial role. Therefore, rural households' external-coping capacity is also an important factor affecting their disaster risk perception and behavioral decision-making. Inconsistent with the hypothesis H1b, this study found that in the event of a major disaster such as an earthquake, the ability to borrow money from friends and family is negatively significantly correlated with the probability of disaster occurrence, but not significantly correlated with the severity of disaster occurrence. At the same time, in the event of major disasters such as earthquakes, the success of lending money to banks is positively significantly correlated with the severity of disaster occurrence, but not significantly correlated with the probability of disaster occurrence. The possible reasons for the results are as follows: the severity of the damage caused by earthquakes makes rural households more inclined to seek external help from relatives, friends, or banks when they are affected by disasters. When rural households are facing the serious impact of earthquake disasters, they cannot carry out recovery or reconstruction by only relying on their internal-coping ability, thus, they rely more on external support. However, the social networks of rural households are basically in the same county, and some are even concentrated in the same township or the same village. In the face of earthquake disasters, the relatives and friends of rural households may be affected as well. Thus, concerning the possibility of disaster occurrence, rural households are more inclined to seek help from relatives and friends when the internal-coping ability is insufficient, whereas with regards to the severity of disaster occurrence, rural households are more inclined to borrow money from banks when the internal-coping ability is insufficient. Residents' disaster-risk experience is another important factor affecting their disaster-risk perception. However, consistent with H2b, but inconsistent with H2a, this study finds that the severity of residents' disaster experience is significantly positively correlated with the severity of disaster occurrence, but is not significantly related to the possibility of disaster occurrence. The results are different from the findings of Lo and Cheung [15]. Their research has found that residents' disaster experience is significantly positively correlated with the possibility and severity of disaster occurrence. The possible reason is that the damage caused by these two major earthquakes is too serious, and residents in earthquake-stricken areas have a particularly deep memory of the severity of earthquake damage. Therefore, the severity of residents' disaster experience is significantly positively related to the severity of disaster-risk perception. At the same time, earthquakes are low-frequency disasters that may occur only once in several decades. Although people are worried about the damage caused by earthquakes, they still believe that the possibility of recurrence in the next 10 years is relatively small . Thus, in the research area, the severity of sample residents' disaster experience is not significantly correlated with the possibility of disaster occurrence. Additionally, the differences between our study and Lo and Cheung [15] may also be due to the differences in sample areas and disaster risk perception measures. Lo and Cheung's [15] disaster risk perception is measured by a single index, while this study uses factor analysis to reduce dimensions of multiple indexes. In the revised manuscript, we have also explained this situation. In addition, interestingly, this study indicates that respondents' gender, age, education level, nationality, job, and residence time are not significantly related to disaster-risk perception. The possible reason is that devastating earthquakes such as the Wenchuan Earthquake or the Lushan Earthquake have a great impact on people, and the people who have experienced the disaster have an extremely deep memory of the earthquake, thus, there are no remarkable differences in earthquake disaster-risk perception among gender, age, education level, and other personal characteristics. --- Conclusions and Implications Based on the survey data of 327 rural households from four counties stricken by the Wenchuan Earthquake and the Lushan Earthquake in Sichuan province, this study analyzes the characteristics of rural households' financial preparation, disaster-experience severity, and disaster-risk perception. Meanwhile, it constructs OLS models to probe the correlations between rural households' financial preparation or disaster-experience severity and the perception of the possibility and severity of disaster occurrence. Three main conclusions are drawn: As for financial preparation, among 327 sample rural households, rural households' income diversity index and asset diversity index are both less than 0.5, about one third rural households purchase commercial insurance, and less than half rural households have deposits; whenever there is a catastrophe such as an earthquake, about three quarters of rural households can borrow money from banks and can borrow money from friends and relatives. As for the correlations between financial preparation and disaster risk perception, the higher the rural households' total family cash income, the higher the asset diversity, and when rural households can borrow money from relatives and friends whenever there is a catastrophe such as an earthquake, the lower their perception of the possibility of disaster occurrence, the higher the asset diversity. When rural households can borrow money from banks whenever there is a catastrophe such as an earthquake, the stronger their perception of the severity of disaster occurrence. As for the correlation between experience and possible disaster-risk perception, the more severe the disaster experience, the stronger their perception of the severity of disaster occurrence. Meanwhile, the severity of residents' disaster experience is not significantly correlated with the probability of disaster occurrence. Based on the above analysis, this study can also derive some useful policy implications. For instance, although this study found that many indicators of rural households' internal-capacity are not significantly correlated with their disaster risk perception, they are also an important means for rural households to resist external risk impact . This study found that the internal-capacity of rural households is not strong on the whole . The implication for the government is that the government should give more support to rural households, such as helping them find jobs and increasing family income through employment training, trying to implement earthquake catastrophe insurance to help rural households withstand the impact of earthquakes. In addition, this study indicates that rural households' borrowing networks are significantly correlated with their disaster-risk perception , while the total cash income, income diversity, whether rural households have deposits, and whether rural households purchase commercial insurance and have financial preparation are not significantly related to disaster-risk perception. This reflects the importance of rural households' social networks for post-disaster reconstruction. The message to the government is that it is necessary to pay attention to the construction of formal financial institutions and rural households' borrowing networks and offer loan services for rural households in earthquake-stricken areas to help them carry out post-disaster reconstruction. At the same time, through reasonable guidance, there is a need to make full use of the support role of rural households' social networks in their post-disaster recovery. Despite its theoretical and practical significance, this study has some limitations, which can be improved upon in future research. For example, many empirical studies have shown that residents' disaster-risk perception is significantly related to their disaster-avoidance behavior . However, this study only focused on the correlations between rural households' financial preparation or disaster-experience severity and disaster-risk perception and did not explore rural households' disaster-avoidance decisions. Future research, for example, can explore the correlations between rural households' financial preparation or disaster experience and evacuation/relocation behavior decision/intention. For another example, in different empirical studies, the measurement criteria for disaster-risk experience are different, and this study uses the severity of residents' disaster-risk experience, a relatively subjective indicator, to carry out the measurement. Hence, future research can consider using some objective and quantitative indicators to carry out the measurement and explore the influence of disaster-risk experience on residents' disaster-risk perception or disaster-avoidance behavior. --- Author Contributions: Conceptualization, D.X. and X.D.; Formal analysis, Z.Y.; Funding acquisition, D.X.; Investigation, Z.Y., Y.L., K.H., W.Z., and Z.M.; Methodology, D.X.; Supervision, D.X.; Writing-original draft, D.X., Z.Y., X.D., Y.L., K.H., W.Z., and Z.M.; Writing-review & editing, D.X. ---

Sichuan is a province in Southwest China that is famous worldwide for its earthquakes. However, few quantitative studies in China have probed the correlations between rural households' financial preparation, disaster experience, and disaster-risk perception. Using survey data of 327 rural households from four areas stricken by the Wenchuan Earthquake and Lushan Earthquake in Sichuan, the ordinary least square (OLS) method was used to quantitatively explore the correlations between these three factors. The results show that rural households' total family cash income, asset diversity, and whether rural households can borrow money from relatives and friends whenever there is a catastrophe such as an earthquake are significantly negatively correlated with the probability of disaster occurrence. Asset diversity and whether rural households can borrow money from banks whenever there is a catastrophe such as an earthquake are significantly positively related to the severity of disaster occurrence. The severity of residents' disaster experience is not significantly correlated with the probability of disaster occurrence, but is significantly positively related to the severity of the disaster. The research results can provide useful enlightenment for the improvement of financial preparedness and disaster risk management for rural households in earthquake-stricken areas.

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

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

Introduction: The Curious Case of Right-Wing Human Rights Activism When it comes to human rights struggles, a longstanding picture of 'civil society vs the state' emerged, with the former depicted as defenders and reformers and the latter as major transgressors and antagonists. Many have theoretically contested and empirically disproven the idea that civil society organisations are necessarily progressive, pluralist, and democratic, yet the assumption that CSOs are generally for liberal and progressive notions of human rights still lingers . As they are organisationally distinct and institutionally separated from political society, many assume that CSOs favour an expanded, protected, and autonomous civil space to maintain a competitive edge vis-à-vis the state and other pressure groups to advance their respective causes and interests. This reading seeps into scholarly treatments of religious CSOs, too, even though their relationship with notions of universal human rights is complicated, if not contentious . For example, in his influential book, Casanova describes a public or deprivatised religion that operates at the level of civil society as "consistent with modern universalistic principles and with modern differentiated structures". Robert Hefner's pathbreaking study of civil Islam in Indonesia marries the phenomenon with the broader democratisation agenda that heralded the collapse of the Suharto regime. He painted "civil Islam" as the majority's counterbalance to "statist Islam" through its commitment to values of "freedom, equality, and justice" . However, developments in post-Suharto Indonesia that saw the persecution of gender and religious minorities , entrenched moral policing laws, a contentious mobilisation campaign against a Christian mayor, and the empowerment of Muslim vigilante groups such as the Front Pembela Islam challenge the idea that civil society's expansion will necessarily boost the human rights agenda. 1 This sense of disillusionment is compounded by the fact that numerous actors and agents associated with Hefner's civil Islam enabled many of these occurrences . The alarming developments in India, Myanmar, and Indonesia that saw the decline of religious freedom and minority rights following the mobilisation of right-wing religious actors reinforced a conceptual binary that divides non-western CSOs into two opposing camps . One camp rejects 'Western' interpretations of human rights as embedded in the United Nations' Universal Declaration of Human Rights , whereas the other generally accepts and champions it. Heuristically useful as it might be, this categorical distinction speaks very little about a new breed of right-wing CSOs who style themselves explicitly as human rights defenders. These CSOs are willing to work within the international human rights regime, but they also engage in a kind of 'human rights' activism that implicitly subverts, undercuts, and reformulates the agenda to move it away from a normative commitment to protect minority rights, social equality, and religious freedom. Specifically, this paper sheds light on the appropriation of 'human rightism' 2 by right-wing Islamist actors in Malaysia. The picture painted here complicates the idea that nativist political actors most scoffing at the 'Western' human rights regime will always position themselves as rejectionists and outsiders of the enterprise. Rather, what one witnesses is that the more these actors engage in the politics of human rights as fellow activists and putative insiders, the likelier they erode the parameters of what constitutes human rights and the notions of freedom and equality it affords. Even though the protagonists of this study do not openly identify themselves as Islamists, their nativist positioning are inextricably linked to Islamist ideology, grievances, and networks. I will deal with the nativist and Islamist underpinnings of these actors in a later section. However, discussing the relationship between Islam and human rights is necessary. Scholars have long offered sophisticated treatments on the question of Islam's compatibility with the ideas of universal human rights and, more importantly, whether those are the only terms of debate for those seeking a radical vision of global justice and solidarity . Those are not the grounds this paper wishes to tread. It does not debate whether human rights should be universal or particularistic, whether its values should be globalised or decolonised, or whether its historical praxis comprises good intentions or hypocrisies . Rather, my inquiry scrutinises a more practical concern: if we accept that discourses about human rights are inevitably subjected to pluralising pressures, what happens when two understandings of human rights coincide and contend in a Muslim-majority state? Do such contestations improve the lives and protections of the socially marginal and disadvantaged? In our case, what transpires is that a struggle portrayed as dismantling an allegedly hegemonic global Western human rights regime actually contributes to reinforcing local hegemonies based on a Muslim majoritarian worldview. In a world where the nation-state remains the perimeters in which dynamics of exclusion and inclusion play out significantly, any local reproduction of majoritarian hegemonies in the name of human rights is undoubtedly a cause for concern . Müller's account of "paradoxical normativities" in Brunei and Malaysia offers one way to visualise the encounter of contending visions of human rights . He underlines the paradox in how Muslim states Janus-facedly complied with the human rights regime by symbolically committing to a "transdoctrinal justification of human rights" on the diplomatic front and simultaneously enforcing an anti-pluralist brand of Islam on the governing front . My departure from Müller's approach is that I am less interested in documenting various forms of state hypocrisy and violations on human 1 Regarding these incidences, see Hew ; Connley ; Mohamed Osman and Waikar ; Syechbubakr . --- 2 The term 'human rightism' highlights a sense of irony here. The former Prime Minister of Malaysia, Najib Razak, first coined it to denigrate humanism, secularism, and liberalism as threats to Islam . The fact that right-wing Islamist actors appropriated the human rights discourse a few years later to pursue conservative causes associated with sexual morality, anti-minority stances, and political authoritarianism is an ironic twist indeed. rights issues that journalists and groups like Human Rights Watch have meticulously accomplished. Instead, I argue that we must focus on how non-state actors who position themselves as active defenders of human rights capitalise on the liminal space these paradoxical normativities offer when they appropriate the human rights vocabulary and reframe it to justify exclusivist majoritarian social, political, and religious causes. These articulations are impactful reinventions of the human right discourse because they shed any moral commitment to protecting minorities and the socially marginalised altogether. As such, my account builds on similar observations scholars have made when examining right-wing politics in places such as Israel and Europe that saw a "sweeping acculturation of the universal human rights discourse" to legitimise the racist and chauvinistic agendas of actors whose ideological predecessors might have scorned such symbolic associations previously . Whereas these studies focus on actors who adopt an anti-Muslim position, this paper's empirical contribution comes from examining those who advance a Muslim nativist and majoritarian agenda. Right-wing non-state actors' active appropriation of the human rights agenda deserves greater scholarly attention for three reasons. First, such appropriation sustains the appearance of compliance and cooperation in the eyes of external observers, rendering invisible the fact that these actors are working to undermine the human rights agenda significantly in issues concerning the protection of gender, sexual, racial, and religious minorities. Second, because they leverage through a nativist framing, these actors often enjoy the sympathy, if not the tacit support, of political and bureaucratic actors and agents who hold the levers of power in Malaysia's increasing Islamically-oriented ethnocratic regime . Due to a shared scepticism of human rights as a 'Western' conspiracy with other state actors, these right-wing activists' lobbying efforts, unlike their liberal counterparts, can easily translate into concrete policy action . Contrary to their grievous positioning as underdogs having to contend with a 'hegemonic' and 'foreign' human rights regime, these right-wing CSOs work with power holders and brokers, not against them. 3 Third, despite the 'human rights' packaging, the positions held by these CSOs overlap with many social conservatives on morality, sexuality, and family values, enabling them to command a sizable local support. As we shall see, this aspect afforded these activists-many of whom are newcomers to the human rights scene-the social capital to leverage populist pressures to undermine other established local human rights agencies' and activists' legitimacy by labelling them as 'pro-Western', 'liberal', and even 'treasonous' on social media. By advancing a pro-majoritarian version of human rights, they inject ethnoreligious and exclusivist elements, not to mention potentially trans-and homophobic ideas, into local discourses about human rights. The result reshapes public expectations of the role of human rights defenders and overturns the axis of victimhood to portray the majority as the victim of an oppressive Western human rights regime. In short, this paper examines the co-sharing of the human rights rhetorical and institutional space where a globally situated, procedural-centric human rights regime came up against nativist self-proclaimed human rights entrepreneurs who infiltrated its mechanisms and reconfigured its norms while posing as cooperative local partners. It depicts a scenario where semantically recognising an overarching ideal of human rights protection does not necessarily safeguard it against normative and institutional erosion. It shows that CSOs can maintain the human rights façade while acting as cheerleaders of state policies that target, police, and discriminate against socially marginal groupings such as racial, gender, sexual, and religious minorities. --- Methodology and Paper Structure The empirical focus of this paper lies in two areas of interest. The first is the historical and social context in which Malaysia's right-wing 'human rights' activism arose. The second concerns the strategic novelties these right-wing actors introduced, which stood apart from right-wing Islamist actors' more rejectionist 3 This perspective also complicates Hurd's point about the transformative influence of transnational authorities in defining "the terms of religious conflict and coexistence" . In Malaysia, it is local conservative actors who wield such influence, given their proximity to political power. Their appropriation of the human rights discourse further justifies authoritarian exercises of power, as they repackage state-sanctioned religious interventions as protecting one's 'rights to religion'. and hostile treatment of the human rights agenda before the 2010s. It draws heavily from primary sources such as media writings, social media postings, interviews, reports, and publications. It uses a combination of actor tracing and discourse analysis to illustrate the phenomenon. The paper is structured as follows. The first section traces the development of a kind of human rights activism in Malaysia that involves two non-governmental organisations : the Centre of Human Rights Research & Advocacy and the Malaysian Alliance of Civil Society Organisations in the UPR Process that emerged in the late-2010s. 4 I argue that these movements are distinctive in their explicit tactical and discursive focus on 'human rights'. Unlike other Islamist movements, these Islamist NGOs steered clear of party politics. They spent considerable effort positioning themselves as legitimate stakeholders in Malaysia's human rights agenda, such as participating in the United Nations Human Rights Council's Universal Periodic Review and maintaining an active media presence to argue for a more cultural relativist understanding of human rights. Despite their proclaimed 'human rights' niche, I argue that we must understand these groups' activism within the networked effects of other right-wing Islamist affiliates that are also promoting an agenda of Muslim majoritarianism and Islamic cultural supremacy, even as each lobbied in different tones and on different fronts. The second and third sections provide an account of the two main strategies employed by CENTHRA and MACSA, which I examine under the rubric of 'getting in' and 'pushing out', respectively. The former refers to how the two groups position themselves as key stakeholders of the Malaysian human rights agenda through vigorous participation in institutional processes and active appropriation of the human rights lexicon and iconography. The latter depicts an aggressive strategy of exposé, shaming, and critique of local human rights agencies and activists, particularly Malaysia's national human rights institution , the Human Rights Commission of Malaysia , for pandering to 'Western' understandings of human rights. I argue that these activities aimed to erode the legitimacy of many established human rights actors in the eyes of Malaysians. At the same time, they hollow out the human rights agenda of its norms and commitments, especially concerning the protection of religious and sexual minorities. Through these empirically-grounded observations, this paper denotes how active participation in the human rights agenda on the procedural and rhetorical front does not necessarily entail its consolidation. Rather, the human rights regime in Malaysia appears particularly vulnerable to this two-pronged strategy that saw right-wing actors infiltrating to earn 'insider' credentials, on the one hand, and mobilising external pressures to drive the agenda towards majoritarian and chauvinist ends, on the other. --- Setting the Scene: The Historical Context of Malaysia's Right-Wing Activism Identifying what constitutes Malaysia's right-wing activism is challenging because communitarianism is central to the postcolonial nation's social, political, and cultural fabric . The majority of Malaysia's mainstream political parties are race-based, with many defining memberships in explicitly racial terms. 5 For the first 60 years of the nation's history, a Malay-dominated consociational coalition, the Barisan Nasional , led a government that carefully balanced communal interests with maintaining Malay-Muslim hegemony in both politico-economic and sociocultural spheres . The idea of Ketuanan Melayu further legitimised this notion of Malay dominance under the stewardship of the Malay nationalist party, the United Malays National Organisation , which several factors consolidated and institutionalised. 6They include constitutional provisions that recognise the special positions of the Malays,7 the political dominance of UMNO vis-à-vis the other component parties in BN , and the mainstreaming 4 This paper uses NGOs interchangeably with CSOs, giving preference to the former as it comes with less normative baggage. --- 5 For example, the membership for the United Malays National Organisation , the Malaysian Chinese Association , and the Malaysian Indian Congress admits members only from the titular races, although the UMNO later expanded its membership to include non-Malay bumiputeras to make its way into Sabahan politics. Even the religiously denominated Pan-Malaysian Islamic Party is defined by an overwhelmingly Malay-Muslim membership. of Malay-preferential affirmative action aimed at reducing Sino-Malay inequalities in the 1970s. However, the latter has since morphed into a political economy that weaved together statist capitalism, clientelism, and a burgeoning Malay middle class . Further complicating this picture is that the notion of Ketuanan Melayu has gradually taken on the rhetoric of Ketuanan Islam since the 1980s . 8 Juxtaposed onto the idea of Malay political dominance is a line of Islamist reasoning that conflated a narrative of social justice for the Malays-who were seen as economically backward when compared to the Chinese-with an idea of cultural justice that demanded the public sphere be transformed and regulated based on Islamic understandings of public morality, halal consumption, and personal decency . One sees this transformation in the incremental implementation of socio-cultural policies that outlawed extramarital sex, alcohol, and non-heteronormative relationships among Muslims. Nonetheless, such effects bled into non-Muslim lives due to the co-sharing of public spaces, as the constantly bumbling discord about liquor sales control evinces . Nativist arguments supported these conservative yet authoritarian policy positions, with proponents claiming that Islamic values must permeate the social and political space because Islam was the original law of the land prior to the advent of colonialism. I call it nativism because it reflects Higham's classic definition that based it on an "intense opposition to an internal minority on the ground of its foreign…connections" . This nativist streak in Malaysia's right-wing Islamism is most recently seen in campaigns such as the BMF movement launched in 2018, which co-opted Malay nationalist sentiments to function as an unstated boycott of non-Muslim-, or mainly ethnic Chinese-, produced goods . Islam's increased saliency is arguably inexorable given the interlocking of the Malay identity with the religion and the fact that many interpret Malay/non-Malay divisions in Malaysia, though not always neatly, as a Muslim/non-Muslim partition. 9 The trend was also intensified by dynamics of top-down Islamisation as a result of UMNO's competition with its Islamist rival, the Pan-Malaysian Islamic Party , on the one hand; and bottom-up Islamisation that was, following global patterns, advanced by Muslim dakwah movements that peppered the urban landscape since the 1970s, on the other . In short, a conservative ecosystem has long acclimatised Malay politics, especially after the demise of an inchoate leftist streak following state oppression . It is a form of conservatism that rewarded racially and increasingly religiously exclusivist discourses and policies that, in turn, reinforced racial categories and religio-cultural hierarchies. Historically, UMNO's pragmatic leadership circumscribed the parameters of such exclusivism. They were careful to not perturb Malaysia's multicultural peace, as it was conducive to the nation's political stability and economic growth . Put differently, since the 1980s, a Malay-Muslim majoritarian ideology was increasingly institutionalised and normalised yet simultaneously curtailed by an authoritarian state that maintained the equilibrium. 10 If UMNO was the metaphorical lid to these majoritarian forces, its dwindling political strength political strength after the 2008 elections, and even more so after the BN's historic defeat in the 2018 General Elections, saw right-wing majoritarian activism take off via numerous Malay non-governmental organisations . 11 Right-wing populist groups such as the Malay nationalist Pertubuhan Pribumi Perkasa language is the national language. See Moustafa . For the historical context under which the constitution drafted the idea of the Malays' special position, see Fernando . 8 I have revised the translation of ketuanan from 'overlordship' to 'supremacy' to signify the changing meaning of the term. The discourse of power-sharing premised on the recognition of Malay indigeneity has now shifted towards one of majoritarian identity politics in which Islam functions as a symbolic resource to "justify and perpetuate a hegemonic and exclusivist religious discourse" . 9 A Malay is defined as someone "who professes the religion of Islam, habitually speaks the Malay language, and conforms to Malay custom" in Article 160 of the Constitution. Nagata perceptively observed that as language and custom faded away as distinctive identity markers of Malayness due to cultural integration, Islam became "the last bastion" of Malay identity. 10 For example, the existence of the Internal Security Act, Sedition Act, and the Printing Presses and Publication Act has limited the parameters of free speech, often in the name of maintaining racial harmony. Nonetheless, the weight of the law more frequently impacts those questioning UMNO's rule instead of those who spewed anti-minority hate speeches . 11 Abdul Hamid and Ismail's tracing of how a more assertive form of conservative Islamism has risen during Abdullah Badawi's leadership provides a genealogy of said developments, whereby the mutual reinforcement of weakening Malaysia and the Islamist Ikatan Muslimin Malaysia painted UMNO's demise as a result of non-Malays and non-Muslims colluding to overturn the long-established Malay political order. 12 Their messaging often signalled the Malaysian Chinese as the main culprit. We may consider these groups populist, as their activism frames their struggle as 'elite vs masses'. However, their underlying worldview is nativist, wherein corrupted Malay elites have forsaken the indigenous Malay masses by selling out to Chinese interests whom they see as pendatangs . 13 This penchant for populist politics is why social media is so central to their strategies. The platform's aggregating strength allows these right-wing groups to mobilise populist opinion against minority-friendly groups and agendas they oppose, as we shall see later. I categorise these groups as 'right-wing' because they shift a conservative Malay-Muslim nationalist discourse to extreme positions. These groups did so via fiery rhetoric, such as PERKASA's threat to burn Bibles ; advocating for an extra-parliamentary rule, such as ISMA's proposal for "semi-democratic" rule to preserve Malay-Muslim hegemony ; 14 and championing a form of racial exclusivism to replace the old model of Malay-dominated consociationalism with a Malay-Muslim-only government. ISMA, in particular, has spearheaded aggressive online campaigns and electoral strategies to dislodge non-Malay parties from the ruling coalitions of the BN and, later, the Perikatan Nasional . 15 Moreover, it is telling that a party with strong connections to connections to ISMA, Berjasa , have joined a coalition called Gerakan Tanah Air , which fielded no non-Muslim candidates in the 2022 General Elections . Long-time observers will not find ISMA's total political exclusion of non-Muslims surprising, given that it has been their long-term goal . What is more concerning is the gradual mainstreaming of these views. In the 2022 General Elections, PN, which won the second highest number of parliamentary seats, fielded a paltry number of non-Malay and non-Muslim candidates, far fewer when compared to the UMNO-dominated BN. This trajectory of mainstreaming Malay-Muslim majoritarianism appears to mimic that of the Hindu majoritarian Bharatiya Janata Party in India, which currently has no Muslim representation in parliament and does not seem to care about changing the situation as they continued to field a negligible amount of Muslim candidates in elections and propagate an exclusivist rhetoric that clearly targeted the Muslim population . Complicating efforts to call out these actors extreme right-wing positions is their mainstream social existence. Even though academic writings have addressed them as worrying trends, these actors were rarely subjected them to the social stigma that befell far-right groups in the West . For example, they could still meet or share platforms with ministers and senior civil servants, hold columns in mainstream newspapers, and join umbrella organisations with other more moderate Malay leadership and UMNO's diminished electoral fortunes served as the backdrop to the rising influence of right-wing ethnoreligious populists. 12 On Perkasa and ISMA's right-wing activism, see Hamayotsu ; Hew ; Pusat KOMAS ; Malaysiakini . 13 On populist ideology, see Mudde and Kaltwasser . On a sample of writing by the President of ISMA that belied such elite disillusionment, see Ismaweb . --- 14 The article uses the pandemic and Malaysia's political instability to justify its advovacy for semi-democratic rule, in that besides the Prime Minister, all ministers and Government-linked Companies appointees cannot be parliamentarians but rather "technocrats and civil servants". To be fair, such calls to nullify parliamentary rule during the pandemic were not exclusive to ISMA. But proponents were mostly politicians as most CSOs in Malaysia favoured parliamentary oversight instead of doing away with it. The article's claim that the political chaos has led to Malay-Muslim interests being "pawned", when coupled with its call for extra-parliamentary rule, reveal its fascistic undertones. --- 15 The two prongs of ISMA's strategy is as follows. The first is to set up a Facebook page called Gerakan Pengundi Sedar that urged voters to vote for 'credible Muslim candidates'. Of all the candidates they endorse, none of them were from the Pakatan Harapan coalition that advocated for a more multi-ethic model of politics. Second, during the 14 th General Election in 2018, when BN or PAS did not send a Muslim candidate in a Malay-majority area, ISMA, under the banner of Berjasa, would send their own Muslim candidates to contest against the non-Malay candidates, aiming to break the long-term compromise in Malaysia that candidates do not always have to reflect the majority race of a constituency, so that ethnic minorities can still gain meaningful representation. See Abdul Hamid andChe Mohd Razali ; Hew . Malay-Muslim CSOs with little to no pushback. 16 This situation is appalling if one considers that, according to Mudde's definition, we should regard these groups as the "far right" due to their hostility to liberal democracy characterised by extreme exclusivist attitudes towards minorities, including calling them "invaders" at one point . Nevertheless, calling out their ideological positions is fraught with risks, especially if the messenger is based in Malaysia. An academic who called ISMA 'extreme right-wing' in an article saw it withdrawn from its Singapore-based platform after one of the individuals named in the article threatened a lawsuit . The social acceptance of what may look to many as discriminatory, if not extreme, positions further insulate some of these actors from critique, enabling them to infiltrate a traditionally 'liberal' domain such as human rights. --- Majoritarianism as Human Rights: The Centring of Human Rights in Malaysia's Right-Wing Islamist Activism The emergence of right-wing NGOs that position themselves as human rights organisations is connected to the developments above. The gradual weakening of UMNO that resulted in its ouster from government in 2018 and the pervasiveness of what Hew calls "liquid Islamism" emerging from the overlapping between pious, urbane Muslim middle-class aspirations and an increasingly Syariah-minded political consciousness resulted in the mushrooming of numerous Muslim pressure groups in areas ranging from consumerist interests to women's issues . As a social movement, these Muslim NGOs are comprised of urban middle-class activists seeking to actualise their ideas of Islamic rule in Malaysia through non-electoral means, such as ideas propagation, public pressuring, and stakeholder lobbying. Due to their conservative outlooks, they tend to differ, and at times clash, with the more progressive NGOs on issues of sexual morality, censorship, religious freedom, and social inequalities in Malaysia . To be sure, Malay-Muslim groups also inhabit the progressive parts of Malaysia's NGO ecosystem, as in the cases of the Sisters In Islam , the Islamic Renaissance Front , and Komuniti Muslim Universal Malaysia . Their efforts to advance a more humanistic and feminist reinterpretation of Islamic orthodoxies inform their activism . However, by virtue of their professed Malay-Muslim identity, the state and religious establishment significantly censured and ostracised these groups. For example, SIS was labelled 'deviant' in a fatwa ; IRF's book was banned; and KMU activists were doxed and harassed, forcing some to seek temporary asylum abroad . The harsh treatment of these liberal Muslim NGOs, often cheered on by their right-wing counterparts, shows how the contestation of norms and rights has expanded from a 'state-CSOs' axis to a 'culture war' between the CSOs . Tamir Moustafa's work traces this 'war' back to a "rights-versus-rites" binary that saw controversial court cases manufactured into public spectacles that, in turn, drew public opinion and competing activists into skirmishes that sought to settle the question of Malaysia's secular/Islamic identity in a zero-sum and high-stakes manner . These battles' increased stakes eventually leaked into the UPR process, in which Malaysia has participated since 2008. To summarise briefly, the UPR is a process that enables the HRC to review the human rights record of a country every five years. The process involves assessing reports from governments, independent experts, and national stakeholders such as NHRIs and NGOs. After the review, states receive recommendations to improve their human rights condition, which they can accept or simply note. The UPR initially attracted many NGOs from the liberal end of the value spectrum, who organised themselves as the Coalition of Malaysian NGOs in the UPR Process . However, by its third round of review in 2018, the participants had diversified, with groups such as CENTHRA and MACSA emerging as a conservative Islamist bloc. CENTHRA and MACSA arose as the successor to a coalition of Muslim NGOs, MuslimUPRo , that came into the scene during Malaysia's second UPR in 2013. MuslimUPRo argued that the Malaysian government's proposals in response to the UPR process must 16 ISMA, for example, is a member of the Allied Coordinating Committee of Islamic NGOs . In ACCIN, they share a platform with other more moderate Islamist CSOs like the Muslim Youth Movement of Malaysia and Pertubuhan Ikram Malaysia . be "properly based on Syariah laws and the Federal Constitution" . When compared to its successors, MuslimUPRo was more confrontational and disagreeable. In 2013, it attacked COMANGO as foreign-funded and successfully pushed for it to be banned . They also polemically claimed that "unqualified persons" represented Muslim-majority nations while drafting international human rights conventions . Nonetheless, they had dropped these aggressive stances by the time of CENTHRA's and MACSA's establishment. They even obscured the Muslim aspect of their identities by eliminating the term 'Muslim' from their names. At this point, a brief introduction of the two groups is due. Azril Mohd Amin, who once headed MuslimUPRo, founded CENTHRA in 2014. It calls itself a research and advocacy organisation that …provide[s] an alternative to the global human rights perspective in order to offer a more balanced view that is respectful particularly of the Muslim faith and tradition and, in general, the Abrahamic tradition . 17 Nonetheless, the true successor to MuslimUPRo is MACSA, established in 2018. It claims to represent 52 NGOs , with most, if not all, being Muslim NGOs. Many of these NGOs were involved in MuslimUPRo, including the Muslim Youth Movement of Malaysia and ISMA. 18 Co-chaired by Azril Mohd Amin and a University Sains Islam Malaysia lecturer in physiology, Rafidah Hanim Mokhtar , during its founding, MACSA also proclaimed strengthening human rights as its agenda, although it was couched in an Islamist-and nativist-inflected language . We can understand the entry of MuslimUPro, and later CENTHRA and MACSA, into the human rights scene in Malaysia as an act to counterbalance the perceived preponderance of liberal CSOs, such as Suhakam and the various groups within COMANGO in the UPR process. Yet, unlike many Islamist actors who viewed human rights as an outright Western import not worth engaging in, CENTHRA and MACSA have fronted human rights activism as their raison d'etre. They call themselves 'human rights defenders' explicitly and have positioned themselves as informed stakeholders who should be consulted in the UPR process. They have done so by meeting with the Ministry of Foreign Affairs to discuss the UPR, submitting a stakeholders' report to the HRC for review, celebrating International Human Rights Day on their social media page, and even sending delegates to participate in the UPR process as observers in Geneva. --- Key Personalities and Ideological Affiliations Even as it played down such associations, MACSA's Islamist and nativist leanings are noticeable in three aspects: its internal composition, right-wing ideological affiliations, and issue positions. 19 Firstly, the groups that came under the coalition are mainly Islamist organisations, including the Allied Coordinating Committee of Islamic NGOs , one of the largest Islamist umbrella organisations in the country. One of the oldest Islamist NGOs in Malaysia, ABIM, founded by the prominent politician and sitting Prime Minister Anwar Ibrahim, is one of MACSA's members as well. 20Secondly, the group overlaps with the aforementioned right-wing Islamist group, ISMA, in terms of its personnel and public position. Thus, it is hardly surprising that MACSA's most prominent activists have taken some relatively hard-line positions on issues concerning politics, identity, gender, and religion. For instance, the co-chairperson of MACSA, Dr Rafidah, was the information chief of the women's wing 17 "Who we are", at centhra.org/who-we-are/ 18 "MACSA IN UPR 2018", wafiq.my, 30 October 2018. Available at https://wafiq.my/2018/10/30/press-statement-malaysianalliance-of-civil-society-organisations-in-the-upr-process-macsa/ . --- 19 The confluence of Islamism and nativism can be seen in Vedi Hadiz's study of Islamic populism, see Hadiz . I hesitate to use the term 'populism' to discuss MACSA and CENTHRA because they were not involved in the kind of popular mobilisation embarked by populist movements, nor were they enjoying sizeable popular support as groups like the Front Pembela Islam in Indonesia has. of ISMA, which, according to Abdul Hamid and Che Mohd Razali, maintains an "anachronistically xenophobic and ethnocentric worldview" . Back in 2014, Dr Rafidah was herself involved in ISMA's push to get COMANGO banned for challenging "the position of Islam in Malaysia and spreading 'liberalism teachings' backed by Western powers" . She claimed that the "sacrosanctity of Islam is at stake" because COMANGO was pushing for "the flourishing of LGBT culture" . The other co-chairperson of MACSA since 2019, Lukman Sheriff Alias, is a lawyer involved in opposing the Malaysian government's ratification of the International Convention on the Elimination of All Forms of Racial Discrimination . 21 ISMA also took a vehemently anti-ICERD stance, engineering a massive protest by galvanising Malay-Muslim political parties and NGOs . 22 Lukman was reportedly part of a conservative Islamist faction trying to gain hold of Malaysia's relatively liberal Bar Council and a key proponent of legal reforms that would elevate the power of Syariah courts in Malaysia's parallel court system . 23 The former co-chairperson of MACSA and current chief executive of CENTHRA, Azril, was once caught in a controversy for reportedly calling for a ban on Christian evangelicalism, claiming that a "high number" of Muslims were "leaving the faith" . 24 ISMA similarly propagated a moral panic through an conspiracy of Christians "infiltrating" Putrajaya . Thirdly, MACSA primarily directed its human rights advocacy at issues of most interest to proponents of Islamism. On the domestic front, these focused on conceptions of moral sins, such as the LGBT issue, extramarital sex, 25 and alcohol consumption . Their 'human rights' worldview is linked to their push for increased Syariahisation of Malaysian laws, which they believe to be a solution to such social ills . For example, MACSA activists supported a bill called RUU 355 that would have removed the constitutional barrier for the state government of Kelantan to implement Hudud laws that criminalise adultery with punishments that included stoning to death or 40 to 80 lashes for any Muslim caught drinking intoxicating substances . MACSA also criticised many non-Muslim politicians who questioned the bill as politicising "Islamophobia" . These MACSA activists justified their religio-conservative positions through either revisionist legal arguments that claim the constitution underscores Islam's supremacy as the "religion of the federation" in Article 3, 26 or nativist, majoritarian reasoning that "the national identity must be based on the indigenous culture of the nation, with Malay civilisation and culture as well as Islam being the main and important component" . On the international front, issues of Muslim persecution such as the Rohingyan refugee crisis, the Palestinian issue, and the Xinjiang problem remains the mainstay, if not the sole focus, of their advocacy, with much energy spent on highlighting the hypocrisy of the Western liberal order. To summarise, we can view MACSA and CENTHRA as Islamists because they demonstrate notable features of political Islam-in-action. Their activism sought to impose doctrinal purity in public spaces and Muslim private lives, relied on victimhood discourses to create a sense of empowerment, and championed increased Syariahisation as a bulwark against secularism . However, as newcomers to the human rights scene, MACSA and CENTHRA made little effort to combine the universalistic aspiration in the conventional human rights tradition with Islamic teachings. 27 Instead, they have focused on championing an Islamist agenda reframed in nativist and cultural 21 ICERD was ratified by 55 out of the 57 Organisation of Islamic Cooperation nations, so Malaysia is not the norm but an exception. --- 22 On the fracas about ICERD in Malaysian politics, see Jayasooria . --- 23 'On Malaysia's parallel legal system, see Tew . 24 Nonetheless, all demographic projections have shown that the Muslim population in Malaysia is bound to increase to 72 per cent in 2050 from 64 per cent in 2010. See Malay Mail Online . 25 See, for example, Dr Rafidah's position that Malaysia's "education system should teach students that sexual intimacy should only exist within a legal marriage" at Mokhtar . relativist terms. Their ideological worldview also made their 'human rights' agenda exclusionary to the religious, sexual, racial, and gender minorities that historically and today remain the usual target of human rights abuses in Malaysia, although CENTHRA has highlighted issues of statelessness concerning Malaysian Indians and the Orang Asli . --- Discursive Framings and Strategies There is nothing inherently problematic or unique about conservative religiopolitical activism, which one can trace historically to the Asian values debate in Southeast Asia and geographically to conservative evangelical politics in the United States . However, case studies in Israel, where a human rights vocabulary is used to justify a right-wing discourse of 'settler justice', or in Europe, where Generation Identity's "rights to identity" ultimately championed a xenophobic cause, should warn us from taking these 'human rights' turns at face value . In Malaysia, right-wing actors' appropriation of the human rights agenda is a concerning development for two reasons. First, these campaigns redefine the language of human rights to limit its parameters of protection and undercut its potential for emancipation, thereby justifying extending state authoritarianism and the continued marginalisation of disadvantaged and stigmatised minorities. Second, their discourse subverts the content of human rights traditionally aimed at securing the rights of marginalised minorities living under majoritarian pressures. Right-wing 'human rights' narratives flip the discourse by reinventing the 'majority' as the persecuted group, going squarely against academic and activist findings of Malaysia's narrowing religious and cultural space due to state-backed Islamisation pressures . One uncovers MACSA's subversion of the human rights agenda in three aspects of its framing. First, MACSA's stated agenda dilutes the human rights agenda by situating the UDHR within the triple confines of cultural relativism, doctrinal supremacy, and statist exceptionalism. These elements emerge in MACSA's message concerning human rights improvement measures undertaken following the UPR: '…in addition to upholding international human rights instruments such as the Universal Declaration of Human Rights 1948 , the Cairo Declaration on Human Rights in Islam 1990 and the ASEAN Human Rights Declaration 2012 , [they must] also be in tandem with Malaysia's own laws and customs, particularly with the Federal Constitution and the Constitutions and positions of the States existing within the Federation'. 28 There is no question that the human rights agenda has always struggled between universalistic ideals and particularistic contexts, including in Western settings . However, by ringfencing the discourse of human rights within the CDHRI, AHRD, and national laws,29 MACSA narrows the usual scope of protection that the human rights project affords. By conflating higher and humanistic ideals with a meshwork of declarations and national exceptionalisms that preponderantly skew towards protecting pre-existing patriarchal and regime-affirming hierarchies, its version of human rights risks eroding whatever checks and balances against state and majoritarian excesses the project promises-even if only as moral support-to victims of oppression and discrimination . Second, the discourse that MACSA employs obscures and subverts human rights guarantees of freedom and choice with euphemisms such as "religious and health rights of LGBT persons"-the language it used in its stakeholders' report to the UPR Process . These euphemisms diverted the LGBT rights discourse in two directions. The first was a medicalised discourse that depicted LGBT communities as public health issues culpable for the transmission of HIV and other "high-risk 28 "MACSA Formed to Strengthen Human Rights in Malaysia", November 16, 2017, at https://macsa.com.my/macsa-formedto-strengthen-human-rights-in-malaysia/. One should note that the legislation behind the founding of Suhakam only mentioned the UDHR and the Federal Constitution as its reference of the Human Rights Commission of Malaysia Act 1997), which has been a bugbear for right-wing Islamist activists. behaviours" . 30 MACSA activists also condemned the phenomenon as a "lifestyle" stemming from a "liberal fascist" ideology that "goes against the prevailing sentiments and religious concerns of the general public" . They actively pushed for state intervention to protect the "Muslim public against immoral and indecent acts". 31 With a handful of Christian representatives, MACSA activists also invoked the idea that the LGBT 'lifestyle' is against all religious traditions and the principles of "courtesy and morality" within Malaysia's Rukun Negara . 32 The second direction was a 'religious rights' discourse that stressed the LGBT communities' right to "religious input" and education. 33 What these narratives concealed was their support of controversial state-sponsored religious programmes. One example is the Mukhayyam programme that claims to inculcate "spiritual awareness through a religious approach to face the challenges of life and abandon the practice of unnatural sex", which led to comparisons with 'conversion' therapies in the West . Human Rights Watch even describes these programmes as "manipulating LGBT people into believing they are deviant" . Although MACSA insisted these programmes are voluntary, 34 the HRW's research disputed that notion by demonstrating that participants received inducements to participate . MACSA's preoccupation with defending these controversial programmes from criticisms contrasts against its silence on Malaysia's criminalisation of homosexuality and transgender people through Penal Code and Syariah enactments . Put differently, rather than addressing legal and religious-moral stigmatisation of LGBT communities, MACSA shifts the problem to their alleged deprivation of religious and spiritual care, which it never substantiated empirically . Third, MACSA's appropriation of the human rights agenda aims to strengthen a majoritarian-nativist agenda through the creative engineering of majoritarian victimhood. The majoritarian-centricity of MACSA's human rights discourses appears in its founding statement. It argued that the term "indigenous people" in human rights discourse must include the Malay majority. 35 In reality, however, the term occurs specifically in human rights discourses to refer to the aboriginal Orang Asli who face severe social and economic marginalisation . Given their small population, approximately 0.7 per cent of the peninsula's population, this specific term sets the Orang Asli apart from the Malay community in Malaysia, who "constitute the majority and are politically, economically and socially dominant". 36 Even though many of the Orang Asli were not Muslims, MACSA still advocates for their assimilation through "educational and Islamic outreach" to encourage them "to adopt Malay language and to assimilate to Malay culture and customs". 37 The irony is certainly not lost here that, despite their pro-Uyghur positions, MACSA is adopting a vernacular that could easily be construed as entering cultural genocide territory . MACSA's many statements and articles also propagated a victimhood narrative that pictures the majority Malay-Muslim community as systematically subjected to Islamophobia . The Rukun Negara was drafted as a national philosophy after Malaysia's devastating racial riots in 1969. Its five principles are Belief in God, Loyalty to King and Country, Supremacy of the Constitution, Rule of Law, and Courtesy and Morality. The principles themselves are not legally binding and remain a source of contention and semantical acrobatics for proponents of various forms of politics, whether secular or religious. --- 33 "Uphold Religious and Spiritual Values on Sexual Morality and Family Unit.", July 23, 2020 at https://macsa.com.my/ uphold-religious-and-spiritual-values-on-sexual-morality-and-family-unit/ 34 "Mukhayyam: Honour the Religious Rights of LGBTQ People", August 5, 2020, at https://macsa.com.my/mukhayyam-honour-the-religious-rights-of-lgbtq-people/ 35 "MACSA Formed to Strengthen Human Rights in Malaysia", November 16, 2017, at https://macsa.com.my/macsa-formedto-strengthen-human-rights-in-malaysia/ 36 International Work Group for Indigenous Affairs . "Malaysia", at https://www.iwgia.org/en/malaysia.html#:∼: text=As%20of%202017%2C%20the%20Indigenous,collectively%20known%20as%20Orang%20Asal. --- 37 "MACSA Formed to strengthen Human Rights in Malaysia", November 16, 2017, at https://macsa.com.my/macsa-formedto-strengthen-human-rights-in-malaysia/ Alias and Mokhtar 2021). For example, referencing a case where the court ruled that the consent of both parents is needed before a child can be converted to Islam , the stakeholders' report MACSA submitted calls it "the discrimination against parental rights of Muslim reverts", effectively invoking the idea of Muslim supremacy in what is supposedly an issue of co-parenthood . 38 Echoing the use of Hinduphobia to stymie dissent by Hindu nationalists , MACSA also published a report on Islamophobia that condemned perceived negative media depictions of Islam, as well as any criticisms of Malaysia's "Muslim-dominated government", as 'Islamophobic' . By citing scholarly critiques of Islamophobia meant to highlight the plight of Muslim minorities subjected to majoritarian treatment , the report appropriates the moral indignation behind the term to justify its narrative of majoritarian victimhood. 39 Unsurprisingly, it is utterly silent about legitimate minority fears of assimilative pressures and the continuous erosion of their political, economic, and cultural rights in Malaysia . It is also worth noting that MACSA's majoritarian and revisionist interpretation of the human rights agenda did not refer at all to pressing issues that needed international pressure to overcome state inaction, such as two well-reported cases of enforced disappearances in Malaysia. 40 Instead of targeting the socially and politically marginalised, the human rights agenda that groups like MACSA advance merely reproduces the political mainstream that saw minority interests tossed aside when the competition in Malaysia for Malay-Muslim votes intensified from the late 2000s . In other words, such majoritarian appropriation and derailing of the human rights agenda does not broaden the terms of debate but constricts and narrows the circle of victimhood to favour the status quo and all its attendant power imbalances. Worse, it portrays the many racial, sexual, and religious minorities as victors and persecutors, effectively gaslighting minority woes and individual experiences of injustice amidst the rising currents of Muslim majoritarianism in Malaysia . This section has thus far laid out the broader political context, the social ecosystem, and the ideological worldview that sparked the infiltration of a kind of right-wing Islamist activism into the human rights domain. The following section will focus on two aspects of 'human rights' politics that groups such as CENTHRA and MACSA undertook to mainstream their religious majoritarian version of 'human rights'. They include institutional and discursive strategies of 'getting in' that help right-wing actors gain legitimacy in formal human rights processes and aggressive strategies of 'pushing out' that ostracise liberal rivals and status quo gatekeepers through tactics of exposé and public shaming. 'Getting In': Gaining Legitimacy as a 'Human Rights Defender' Despite their efforts to reformulate and resist what they see as 'foreign' human rights norms, actors from MACSA and CENTHRA actively position themselves as 'insiders' to the cause. Their nativist positions notwithstanding, these groups often resort to English as their primary medium of communication. This strategy dovetails with the fact that English remains the working language for human rights advocacy in Malaysia and internationally. Echoing Generation Identity's appropriation of symbols associated with Amnesty International , MACSA's full name, the Malaysian Alliance of Civil Society Organisations in the UPR Process, bears a striking resemblance to COMANGO's . Notably, both use a similar blue hue in their logos. Most tellingly, when COMANGO raised concerns about MACSA having an almost identical name yet adopting abjectly contradictory stands on issues of "female genital mutilation or cutting, whipping, polygamy, and women's and girls' unequal 38 Note the use of the term 'Muslim revert' in the report, which is the preferred terminology of some dakwah movements, implying a return to an 'original' state. The term contrasts with 'convert' that highlights change, which arguably speaks better to a scenario that necessitates readjustments from all parties, such as in the case of a child's religious upbringing when one parent converted. --- 39 Notwithstanding the empirical fact that Malaysia's Head of State, all its Prime Ministers and deputy Prime Ministers, all senior ministers in the PN government , its head of police and military, and more than 80 percent of the civil service are Malay Muslims. inheritance" , MACSA fired back at COMANGO for their "unprovoked, malicious attacks on their fellow human rights defenders ". 41 This effort to build 'insider credentials' as a human rights defender benefitted from MACSA's active participation in the UPR process, such as submitting their stakeholders' report and sending a delegate to the UPR sessions in Geneva. The group also provided training for those wishing to participate in future UPR processes, a move aimed at breaking the hold of liberal human rights actors on these mechanisms. This newfound proclivity towards technocratic activism that departs from the kind of protest and mobilisational politics in MuslimUPRo days helps sharpen MACSA's image as a civil and legitimate stakeholder within the human rights agenda. Despite their synergistic origins and alignment in ideological positions, MACSA's leaders have softly distanced themselves from ultra-conservative groups such as ISMA to focus on their human rights activism. 42 This decision, in turn, enhances MACSA's appeal to the middle-class Malay-Muslim bourgeoisie that prefers a more intellectual outlook in one's activism . This strategy of 'getting in' appears to be astonishingly successful given that, despite being a newcomer to the scene, MACSA was one of the few 'human rights bodies the Ministry of Foreign Affairs consulted in 2018 when formulating a new foreign policy framework . MOFA cemented their legitimacy as 'human rights defenders' by engaging MACSA as the putative Islamic bloc alongside other human rights stakeholders such as Suhakam and COMANGO during the UPR process in 2018. Astoundingly, this event happened during PH's administration . Logically, PH should have been less friendly to actors with putative ties to right-wing Muslim NGOs like ISMA, as they led a vehement oppositional campaign against the PH government they deemed anti-Malay and anti-Islam . Interestingly, media reports had labelled MACSA as "human rights defenders", even as one journalist acknowledged COMANGO's and MACSA's clashing interpretations of human rights, not to mention the latter's smear campaign against the former a few years earlier . By 2021, MACSA and CENTHRA gained column spaces in Malay and English mainstream newspapers, such as New Straits Times, Berita Harian, and Utusan Malaysia, where their activists frequently wrote about human rights issues . Nevertheless, successfully 'getting in' was not unexpected, as MACSA activists already enjoyed considerable 'insider' access. For a start, the group's conservative Islamist take on human rights issues has always enjoyed some degree of sympathy and support from many within Malaysia's civil service, particularly the Islamic bureaucracy. The Federal Department of Islamic Development of Malaysia has collaborated with various Islamist NGOs, including ISMA, to counter 'liberal' causes in Malaysia . The Majlis Agama Islam Wilayah Persekutuan reportedly sponsored MACSA's delegation to Geneva. 43 Moreover, Azril Mohd Amin, the head of CENTHRA, was a special officer to Malaysia's 8 th Prime Minister, Muhyiddin Yassin , giving him insider access due to the "social and Islamic affairs" clusters he oversaw . After Muhyiddin's resignation, Azril was appointed Chief Executive Officer of the Institute Masa Depan Malaysia , a think tank linked to Muhyiddin's party, the Malaysian United Indigenous Party . 44 Dr Rafidah, on the other hand, is a public university professor who, as of this writing, serves as a member of the Women's Council of the Yayasan Dakwah Islamiah Malaysia -a state-funded body coordinating the dakwah activities of Muslim NGOs. 45 She is also the President of The International Women's 41 "MACSA : COMANGO Attack Of Fellow Human Rights Defenders Smacks Of Diversion And Desperation.", 28 June 2018. Available at https://wafiq.my/2018/06/08/comango-attack-of-fellow-human-rights-defenders-smacks-of-diversion-and-desperation-macsa/ . --- 42 For example, MuslimUPRo's push for COMANGO to be banned in 2013 was complemented by ISMA's campaign to collect one million signatures in support of the call. See Human Rights in ASEAN . --- 43 "MACSA Formed to Strengthen Human Rights in Malaysia", 16 November 2017. Available at https://macsa.com.my/macsaformed-to-strengthen-human-rights-in-malaysia/ . --- 44 "Institut Masa Depan Malaysia buat kajian mendalam hala tuju parti, orang Melayu [Institut Masa Dean Malaysia to research about the future of the party and the Malays]", Berita Harian, December 30, 2018 at https://www.bharian.com.my/ berita/politik/2018/12/514530/institut-masa-depan-malaysia-buat-kajian-mendalam-hala-tuju-parti. 45 "President's Biography" at https://wafiq.my/biodata-presiden/ Alliance for Family Institution and Quality Education -also part of MACSA-working with the religious authorities in Malaysia in their Mukhayyam programmes that claim to serve those who have 'repented' from their LGBT lifestyles. 46 Put differently, despite their polemics that 'human rights' is merely a playground for the liberal detached elites, the prime movers of this conservative, nativist, and Islamist version of human rights activism in Malaysia are very much a part of the upper social classes too. 'Pushing Out': Networked Assault on Suhakam and Human Rights Activists CENTHRA's and MACSA's strategy of positioning themselves as competent human rights insiders also generated substantial pressure for many established human rights organisations, such as COMANGO and Suhakam. Acting as dedicated 'human rights' observers, these groups often resorted to critiques and exposés to push 'liberal' human rights organisations into public attention to invite state intervention or public backlash. I have already discussed efforts to get COMANGO banned in the early 2010s above. Recently, these groups have directed efforts of 'pushing out' at Suhakam, admittedly the most important party to Malaysia's UPR processes, given its status as the NHRI. At this point, it is worth briefly surveying Suhakam's role, which has been a matter of fierce debate. Established in 2000 under the Human Rights Commission of Malaysia Act 1999, Suhakam is a statutory body that enjoys an international mandate established by the Paris Principles, which guarantees it "some measure of financial, personal, and institutional autonomy from the government" ). In practice, however, Suhakam is still dependent on state funding and appointments and plays more of an advisory and educational role in mediating between international norms and local contexts to advance human rights agendas . By having an investigative mandate that allows the agency to examine and report on allegations of human rights abuse , Suhakam often finds itself in an unenviable position where human rights NGOs accuse it as being "toothless" and the government sees it as a nuisance -37). A fair assessment of Suhakam would be that it helps with the "popularization of human rights" , even if the agency maintains strict 'no-go' zones on issues of race and religion, directly contradicting the Paris Principles' special emphasis on combatting racial discrimination. 47 Even as Suhakam's silence on many racial and religious discrimination issues exasperated critics, human rights NGOs have thus far been able to count on Suhakam as a distant ally to uphold human rights standards that are, at least nominally, anti-authoritarian and committed to protecting minority rights. However, that could change as right-wing 'human rights' activists have astutely targeted Suhakam itself as a site for contention, infiltration, and subversion. Although it has maintained a working relationship with Suhakam on selected issues such as child rights and the Convention against Torture , 48 MACSA has resolutely disagreed with Suhakam on topics such as abolishing the death penalty and Sedition Act, child marriage, and tackling discrimination towards ethnic, gender, and sexual minorities. Concerning these issues, MACSA hewed to the position of the conservative pro-Malay, pro-orthodox Islam establishment, whereas Suhakam took more progressive positions. 49 As noted above, MACSA's vision of empowerment for the Orang Asli aspires to assimilate them as Muslims, whereas Suhakam has criticised covert efforts to convert the Orang Asli -24). MACSA couched its disagreement with Suhakam in cultural relativist arguments. It accused Suhakam's positions as primarily based on the UDHR and not the CDHRI and AHRD that better reflected the region's and Malaysia's religio-cultural context . Because the Human Rights Commission of Malaysia Act 1999 did not include the two declarations, MACSA also pushed for its amendment, demonstrating its appetite for institutional reforms that went beyond the aggressive protest politics of the past . In any case, any sign of collegial disagreement between Suhakam and MACSA all but disappeared when news about the agency researching the 'Feasibility of Having Legislation of the Recognition of a Third Gender in Malaysia' leaked in June 2021. Accusing the agency of being against "all faiths" in an English-language article, Dr Rafidah lambasted it for having "exposed their own lack of independence and blind deference to whatever external pressures that are being wielded upon them to promote this immoral agenda" . In another Malay-language article, she argued that, for Muslims, secular principles of human rights were not harmonious with religion and especially singled out the Muslim commissioners for "adhering to the Paris Principles rigidly" to the extent they went against Islamic teachings and the Constitution . 50 This line of critique, and worse, its backsliding to ad hominem attacks, was taken up by ISMA and later the Pertubuhan-Pertubuhan Pembela Islam , then headed by a former President of ISMA ), Aminuddin Yahaya . 51 On one of the Facebook pages that ISMA managed, a posted image contained the faces of Suhakam's commissioners under the title "those responsible for the maliciousness of Suhakam" . The post called out Suhakam for its five 'sins': striving to recognise the third gender; legalising prostitution; pushing the government to provide special facilities to the transgender community; normalising the idea of non-binary gender by including it in their report, and opposing the criminalisation of Muslim apostasy in Malaysia. Three days later, a MACSA Facebook post again featured the nine Suhakam commissioners with their photos displayed alongside a message protesting Suhakam for allegedly trying to recognise a third gender . Aminuddin went further by listing the names of the four Muslim commissioners and rhetorically asking, "What were their functions in the agency, if not to protect Islam"? 52 One of the commissioners, Professor Nik Salida, an Islamic law lecturer, was also singled out. Figure 3 shows an image posted on Facebook where her face, paired with a purported statement of hers claiming "all gender identities and sexual orientation should not be discriminated", was laid next to the then Minister of Islamic Affairs' claim that "Malaysia rejects LGBT and will not recognise the third gender". 'Outing' the Muslim commissioners in this way helped polemicise the issue through the lens of religious identity. Soon, netizens left comments claiming that the problem with Suhakam was that the majority of the commissioners were non-Muslims . Aminuddin also called for action against Suhakam, including changing the line-up of its commissioner to include more Islamic scholars . 53 Doxxing attacks also befell a Suhakam staff member whose face was appended on articles that called him out for saying that stateenacted Syariah laws can be criticised because they are ultimately "man-made". 54 These naming and shaming tactics were effective because they exploited Suhakam's precarity and exposure to state manipulation on the one hand and populist anger on the other. Notwithstanding its stature as Malaysia's NHRI that comes with certain safeguards of institutional autonomy, the government often subjects Suhakam to its pressure and influence. For example, in 2016, Suhakam had to endure a 50 per cent funding cut from the Najib administration that had proclaimed "human rightism" as its enemy 50 The article is muted, however, in explaining how exploring the issue of non-binary genders in research infringes the Malaysian Constitution. --- 51 Pembela started out as an ABIM-led movement agitating over controversial court cases involving Muslim converts and apostasy. See Abdul Hamid . In October 2022, Aminuddin Yahaya left his post as Pembela's President to run as an election candidate of GTA, which ISMA's affiliate Berjasa was also part of, in Malaysia's 15 th General Elections. Despite claiming to be non-partisan, like ISMA, Pembela's Facebook page kept echoing GTA's ultranationalist narratives of the Malays and Islam under threat. --- 52 "Rupanya SUHAKAM diterajui Profesor Syariah, Tokoh Maal Hijrah, ahli majlis agama'tapi mana mereka? [So Suhakam is led by Islamic law professor, prominent Islamic figure, and member of the Islamic council-but where are they?]", beritamelayukini, 18 October 2021. Available at https://beritamelayukini.com/2021/10/18/rupanya-suhakam-diterajui-profesor-syariahtokoh-maal-hijrah-ahli-majlis-agama-tapi-mana-mereka . Available at https://www.samudera.my/tuhan-tak-turun-bersidang-di-dun-ketua-undang-undang-dan-perjanjian-antarabangsasuhakam/ . . Even the elected PH government that was more amenable to the human rights agenda had continued the opaque practice of appointing Suhakam commissioners without any parliamentary oversight . Suhakam's porosity to state intervention renders it more vulnerable to media campaigns and institutional capture mounted by conservative and right-wing elements. Moreover, significant quarters within the state-whether politicians, academics, or civil servants-have long considered the agency too pro-Western and anti-Islam. Such scepticism of the human rights agenda is evident in a paper co-authored by the Secretary-General of the Ministry of Home Affairs that counts "fanatical human rights groups" as one form of "violent extremism" . Thus, 'pushing out' the commissioners who owed their appointment to a government that contained an Islamist partner 57 achieved two motives: exposing the commissioners to public shaming, and shoring up public expectations for the appointment of more 'Islamically-compliant' commissioners in the future. Without the state showing support or making any guarantees of protection, these pressure and intimidation tactics, even if mainly on social media, appeared to have worked. 58 On 15 December 2021, to the shock of many human rights activists, Suhakam released a statement clarifying its stance on religious rights and the LGBT issue, conceding vaguely to the Islamists' and cultural relativists' positions. For example, the statement asserts that enactments against Muslim apostasy are legitimate in Malaysia When this article was written, PAS was still part of the BN-PN government that ruled Malaysia from February 2020 to October 2022. However, after the General Elections on 19 November 2022 where no coalition managed to achieve a simple majority, the new PH-led government has, as of writing, not incorporated PAS. However, the political situation remains fluid and PAS may very well return to government if the current government collapses. under state-level Syariah laws, contravening Suhakam's longstanding position on religious freedom. The statement also claims that, even as the Federal Constitution guarantees fundamental rights for the LGBT community, such rights… …are not amenable to them practicing a lifestyle that is contrary to the cultural and religious norms of this nation. Besides individual rights, human rights law should also protect collective rights and be balanced with the imperative to safeguard Malaysia's multicultural peace. 60 Additionally, Suhakam's commissioner line-up has tilted towards the conservatives. The new chairperson appointed in mid-2022 has argued against Malaysia joining the Rome Statute and ICERD. One of the new commissioners was a former director-general of JAKIM, an agency that often butted heads with human rights NGOs because it accused the agenda of being anti-Islam . It would appear that in return for their activism to push out the more 'liberal' commissioners, right-wing Islamists were rewarded with appointments more sympathetic to their conservative Islamist cause. Given the aggressive lobbying and personal attacks, it is difficult to take this concession as simply an outcome of civil debate between particularistic and universalist proponents of human rights, which the normative literature on human rights tends to assume. The tussle was hardly ever framed in theoretical or philosophical terms, nor did one treat the other as a worthy, equal dialogue partner. Suhakam's precarious position as an NHRI holding relatively liberal positions within a conservative Malay ethnonationalist regime that included an Islamist governing partner rendered it almost defenceless in the face of these attacks, more so when the political parties in the opposition were hesitant to support the agency for fear of a conservative backlash. The harnessing of social media's galvanising potential also helped these right-wing actors penetrate the insular and bureaucratic world Suhakam usually operates in, forcing the agency and its leadership out of their comfort zone to face semblances of majoritarian pressure as these right-wing activists claimed to be speaking for the 'silent' conservative Malay-Muslim majority. They mounted these networked and seemingly coordinated attacks against Suhakam across multiple platforms , creating a wave of populist anger Suhakam alone seemed ill-equipped to respond. Most notably, these interlocutors kept questioning Suhakam's legitimacy in representing the interest of the majority Malay-Muslim community as a state-funded body, blithely dismissing Suhakam's mandate as human rights agency and not a communitarian one. 61 --- Conclusion This paper's objective lies in identifying novel strategies of 'human rights' activism that turned human rights discourse into a cover for undermining it. These strategies include appropriating human rights rhetoric to soften elements that belie ethnoreligious supremacist thinking, tapping into one's proclaimed status as a human rights defender to deflect criticisms for advancing positions that violate human rights, and maintaining a technocratic sheen to convey legitimacy for one's activism. By strategically promoting revisionist and majoritarian-friendly interpretations of human rights, right-wing actors further undermined the precarious legitimacy and limited autonomous space that Malaysia's embattled human rights activists and the NHRI occupy. Put another way, they attenuated the enormous challenges already faced by these human rights activists in their struggle to advance civil liberties and to preserve the nation's multicultural social fabric 2019). This article has opted for a two-step analysis to untangle these developments. First, I discussed its historical context, namely the rise of right-wing ethnoreligious forces in the face of increasing political instability in Malaysia. Second, I highlighted two tactics right-wing NGOs employed to position themselves as legitimate 'human rights' defenders. For heuristic purposes, I name them strategies of 'getting in' and 'pushing out'. The former entails institutional participation and social media campaigns that position CENTHRA and MACSA as bona fide human rights stakeholders and experts. The latter refers to aggressive and networked campaigns of 'outing' that name and shame Suhakam and other established human rights NGOs as un-Islamic, overly liberal, and uncritically parroting the 'Western' agenda. These strategies operated in tandem to rally sympathetic opinion from conservative elements within and without the state to pressure Suhakam to accept a majoritarian, cultural relativist understanding of human right. They also gradually excluded proponents who held 'liberal' views from state institutions and engagement. What I described in the Malaysian case is not unique domestically or globally. Domestically, the right-wing human rights activism I highlighted is not an isolated venture but part of a broader revisionist project right-wing actors undertook to selectively appropriate intellectual currents popularised in the West, such as decolonisation, to perpetuate majoritarian fears. Ironically, despite its strong anti-West sentiments, these right-wing Islamist-led projects often pantomime far-right movements in the West that 61 For example, the chairperson of MACSA, Lukman Sheriff, shared an online panel with Pembela's Aminuddin Yahaya and the head of Persatuan Pengguna Islam Malaysia to discuss the 'relevance' of Suhakam. See the Facebook video on Demi Malaiu, 25 June 2021. PPIM and Aminuddin were the key organisers of a nativist 'Buy Muslim First' campaign in 2019 that exhibited subtle but certainly notable anti-Chinese sentiments. See Hew . also deploy conspiracy theories such as white genocide and the Great Displacement to propagate a narrative of victimhood to justify white supremacy and xenophobia . Whereas Malaysia's situation is not as worrying as that of Europe or the United States, outlandish theories such as 'Malay genocide' are present in the mainstream if one knows where to look for them. 62 In other Muslim-majority states, similar trends occur too. The veiled anti-Chinese sentiments in Malaysia's right-wing Islamist human rights narratives are not unfamiliar to those who have read Hadiz's account of Muslim populism in Indonesia, which often reimagines the ethnic Chinese Indonesians as the persecutors of the marginalised ummah . CENTRHA's and MACSA's "neo-conservative rationality", which conceives the heteronormative family as "the kernel of social order" and its strengthening as the "effective remedy" for various social problems, has surfaced in Turkey as well . In Turkey as in Malaysia, such neo-conservative thoughts emerged as the neoliberal state receded from providing welfare and regulating economic relations. Alas, despite the worsening inequality , these right-wing Islamists primarily confined their calls for state interventions to the cultural sphere instead of socioeconomic ones, rendering them unable to energise an 'elite vs masses' form of populist politics that may lead to greater democratisation and genuinely redistributive outcomes . This dragging of Malaysia's 'cultural wars' into the human rights domains by right-wing actors also sustains three further observations that shed light on the future of human rights politics in the country. First, the conventional understanding that human rights activism is the monopoly of urbane, cosmopolitan, and progressive liberals no longer stands true. Whereas one can undoubtedly use the first two descriptors to characterise the protagonists identified in this paper, the seeping of neoconservative ideas into the human rights arena also reflects the rise of a new class of Muslim professionals who can capitalise on their resources and access to funds, research, and lobbying to redefine the ethical grounding and political priorities of the human rights project. 63Second, the mainstreaming of a revisionist and majoritarian-friendly interpretation of human rights also foreshadows more trouble for progressive human rights NGOs. Due to the progressives' ideological, historical, and institutional distance from the state, political elites continually desire to replace them with a more regime-friendly set of human rights 'defenders', especially when lobbying efforts from the conservatives are underway. Malaysia's democratisation, which has not produced the more liberal civil society political scientists hoped for, exacerbates this situation. Instead, the political fragmentation amongst the Malay-Muslim parties, which led to greater uncertainty in their electoral fortunes, has produced two outcomes: the increased influence of the Malay-Muslim-dominated civil service and politicians' willingness to engage with fringe influencers and radical ideologues to widen their appeal as they grapple with the seemingly impossible task of securing a majority from a fragmented Malay-Muslim vote base . These developments led to considerable ideological hardening in state religio-cultural policies on alcohol, censorship, gender and sexuality rights, apostasy, public decency, and intellectual freedom . The proximity between these right-wing NGOs and those in the corridors of power also raises the prospect that their activism, even if largely civil by method , will lead to outcomes that are inherently uncivil. Lastly, right-wing actors' appropriation of the human rights agenda also underscores the discourse's recognition and moral capital, including amongst conservative and nativist actors who have long felt alienated from the agenda's purported Western liberal biases. However, if this double-play of rhetorical approval and content subversion continues, by the time these right-wing actors earned their 62 See, for example, this book published by an ISMA-affiliated think tank entitled Colonial Urbanisation and the Elimination of the Malay Race in Malaysia that argues that the Malays are facing 'genocide' from first the British, and later the ethnic Chinese . This use of an 'academic' veneer to propagate and buttress racist, unethical, and academically dubious positions in Malaysia is nothing new. Rahman , for example, counts up to "119 academic articles published in unscientific, questionable, and/or unaccredited journals" in support of conversion therapy and transphobia. long-yearned-for status as 'human rights defenders', the human rights agenda-one defined by a fierce commitment towards minority protection, universal rights, and constraining authoritarianism-will look very different from where it started.

Scholarly treatments of the human rights agenda tend to posit civil society organisations (CSOs) as its defender and the state and mainstream political actors as its violators. Even when raising the problem of an 'uncivil society', the literature labels these CSOs as reactive and hostile to the human rights agenda they perceive as 'Western' and 'foreign'. I argue that these treatments of the issue overlook another phenomenon: the emergence of CSOs that adopted the language of human rights and participated in its formal processes yet subtly redefined, subverted, and undermined the core commitments of the human rights agenda. This paper discusses such developments by referencing right-wing non-governmental organisations (NGOs) in Malaysia that redefined the parameters of the human rights agenda to undercut state commitments to protect religious freedom, sexuality rights, and gender minorities. Through actor and discourse tracing, this paper illustrates how right-wing Islamist NGOs employed a novel two-pronged strategy that no longer openly repudiated the human rights agenda but continued to erode, eviscerate, and reformulate its contents and principles. The first prong involved institutional measures of 'getting in' to gain legitimacy by participating as a stakeholder within local and international human rights processes. The second prong encompassed social strategies of 'pushing out', whereby actors and their networks mobilised populist pressure to expose, ostracise, and subvert established human rights norms, institutions, and actors.

RESEARCH livelihoods through cottage industries, the proportion of the day spent at home may be higher still, especially among childminders, children, the elderly, and people with preexisting ill-health conditions. [1] The SA city of Port Elizabeth is located on the coast of Eastern Cape Province. Port Elizabeth houses one of the country's busiest seaports, the deep-water Port of Ngqura, two large industrial areas and several large motor vehicle assembly plants. Despite the potential for Port Elizabeth industrial operations to be a source of public exposure to a wide range of associated pollutants, there is a dearth of environmental and health information on local communities, especially in relatively impoverished Port Elizabeth neighbourhoods or townships located in close proximity to sites of pollution. --- Objectives To investigate the living conditions and health status of communities in two such townships: Walmer Township and Wells Estate. The findings provide important insights into local environmental and health concerns and needs in the two communities, and a baseline against which the impacts of ongoing industrial development and emissions , as well as any interventions which may be implemented, could be measured. --- Methods In May 2016, the South African Medical Research Council and Nelson Mandela University, together with the Nelson Mandela Bay Municipality, embarked on household surveys in two low-income Port Elizabeth neighbourhoods, namely Walmer Township and Wells Estate. Data from the 2011 SA census indicate that ~19 000 people lived in each of the study sites. [8] Walmer Township is one of the oldest townships in Port Elizabeth and is currently flanked along its southern border by the city's airport . Wells Estate is located ~20 km from the centre of the city of Port Elizabeth, and close to two major industrial zones . The Markman Industrial Area is the older of the two, and houses an abattoir, a tannery, and cement, steel and brick manufacturers, among other industries. The more recently constructed Coega Industrial Development Zone lets space to a range of industries, including manufacturers of vehicles, wind towers and cement, a steel mill, aquaculture, cold storage and processing of agricultural produce. The Coega IDZ also has the infrastructure to support nuclear, conventional and renewable energy projects, as well as an oil refinery. Forming part of the Coega IDZ is the deep-water Port of Ngqura, the third-busiest container port in SA. [9] There are plans in place to expand the portfolio of industrial operations in the Coega IDZ. Wells Estate was established in 2001, when low-cost housing was built for ~300 families that had been displaced in order to construct the Coega IDZ and the Port of Ngqura. [10,11] Ethical approval for the study was obtained from Nelson Mandela University prior to commencement (ref. --- RESEARCH were ensured by removal of all identifiers, such as names of the participants, and allocation of a unique study number to each study participant. Approximately 120 households per site were randomly selected for inclusion in the study using town planning maps. In 2016, following written informed consent, one household member of at least 18 years of age was interviewed to obtain information on factors including household sociodemographic status, perceptions of the living environment and housing conditions, and health status. Responses were entered on site into a hand-held digital device preloaded with the study questionnaire. The software and services of Mobenzi Researcher , a data management system, provided real-time access to uploaded data, allowing the study co-ordinator to monitor data collection activities. Data were analysed using Stata SE, version 15 . Categorical data were described using frequencies, proportions and percentages. Continuous data were presented as means, medians and measures of spread. The outcome variables were upper and lower respiratory tract infections. Upper respiratory tract infections were defined as a wet or dry cough, runny or blocked nose, fever and chills, chest pain, earache, headaches, rapid breathing, sore throat, sneezing or teary/watery eyes, experienced by participants or household members during the 2-week period prior to the interview. Lower respiratory tract infections were bronchitis and pneumonia. Univariate analyses for sociodemographic and environmental characteristics and respiratory health outcomes in each site were compared using χ 2 tests. The level of significance was taken at p<0.05. For the multiple regression models, new binary variables were created for upper and lower respiratory tract infections. Participants were considered to have an upper respiratory tract infection if they presented with one or more symptoms. Participants who had bronchitis or pneumonia diagnosed were recorded as having a lower respiratory tract infection. Independent variables were included in the regression model if the p-value was <0.05, and adjusted odds ratios were calculated. --- Results The study response rates in Walmer Township and Wells Estate were 68% and 85%, respectively. Lack of an eligible respondent at home at the time of the field visit was the main reason for not being included in the study. In Walmer Township, political unrest prevented access to some of the selected study dwellings. While the mean age of the head of the household differed significantly , the two communities were similar in respect of a range of socioeconomic and demographic factors . Most household members had been born in the Eastern Cape, the province in which the city of Port Elizabeth is located. The vast majority spoke isiXhosa at home. Low proportions of household heads in both communities had achieved tertiary education . More than one-third of adult household members in both communities were unemployed; consequently, average monthly household incomes were low and there was a high level of reliance on state financial grants . Access to medical insurance was also low. However, more households in Walmer Township relative to Wells Estate had been able to save money . The median dwelling age was relatively high in Walmer Township compared with Wells Estate . Dwellings in both townships had a median of five rooms, and households comprised a median of four people. Electricity was the main fuel used for cooking in both communities , and 37% and 38% of households in Walmer Township and Wells Estate, respectively, included someone who smoked . To generate additional income, ~33% of Walmer Township households operated at least one cottage industry at home, of which 44% involved activities potentially associated with toxic metals, for example spray painting, hairdressing and car repairs. The remaining 15 households generated an income through activities such as needlework, photography, painting and tiling. In Wells Estate, ~18% of households operated at least one cottage industry, of which 50% were metal-related . The remaining households were involved in money lending, miscellaneous sales, beadwork and laundry services. Fig. 3 shows the top-ranked monthly household expenditures. It can be seen that in both sites the biggest share of household expenditure was on food supplies, followed by debt servicing and education. In general, household expenditure was higher in Walmer Township than Wells Estate, apart from transportation, rent/bond payments and medical expenses, on which Wells Estate residents spent more . Structural conditions of dwellings in Walmer Township and Wells Estate as reported by the respondents are shown in Fig. 4. The presence of cracks in the walls of dwellings predominated in both study sites , followed by peeling paint , leaking roofs and broken windows. Table 2 sets out the responses given when interviewees were asked about their perceptions of selected aspects of the local environment, as well as self-reported ill-health conditions among household members. More respondents in Wells Estate relative to Walmer Township reported major problems with indoor dust , as well as with odours in the neighbourhood. Similarly, in terms of ill-health symptoms, there was a higher level of reports of 'wet cough' , rapid breathing , sneezing and teary/watery eyes in Wells Estate relative to Walmer Township. Self-reported levels of pneumonia, bronchitis and tuberculosis were similar in the two communities. The results of univariate analyses to explore relationships between risk factors and health status are set out in Table 3. Self-reported pneumonia and bronchitis were significantly associated with low income levels 0.791; p=0.056), having a child aged <5 years in the household , living in a dwelling with cracks in the walls and overcrowding . After adjusting for potential confounding factors, having a child aged <5 years in the household remained significantly associated with elevated levels of bronchitis and pneumonia. The wide confidence intervals are probably due to the small sample size, and this result should be viewed with caution. Perceptions of dust inside dwellings, cracks in walls, bad odours in the neighbourhood, air pollution in the neighbourhood, and overcrowding in the dwelling and neighbourhood as 'major' problems were significant in the univariate analyses. However, only air pollution in the neighbourhood retained a significant association with upper respiratory infections after adjusting for confounding factors. --- Discussion This is the first detailed description of the living conditions and health status of two poor communities in one of SA's few coastal industrial cities. The results indicate high levels of poverty in RESEARCH both communities, evidenced by high unemployment levels, low household incomes, heavy reliance on state support, low savings capacity and limited affordability of medical aid. Unemployment levels in Walmer Township and Wells Estate were higher than provincial and national unemployment rates. [12] A further indicator of the degree of poverty in both Walmer Township and Wells Estate was that during the year of fieldwork, debt servicing was the secondranked expenditure item, which inevitably constitutes a further drain --- RESEARCH on already constrained household financial resources. The WHO Commission on Social Determinants of Health has described poverty and poor living standards as powerful determinants of ill health, overwhelming the health impact of lifestyles and medical care, for example. [13,14] Within the home setting, the operation of cottage industries associated with pollutant emissions, such as spray painting and electrical appliance repairs, while contributing to household coffers, constitutes an insidious cause for public health concern. The risks are highest for young children, the elderly, and those who are unemployed or have pre-existing ill-health conditions, who may spend most of their time in the home environment. [15] Apart from their poverty, a second layer of health vulnerability for the two study communities arises from the poor quality of their housing, including high levels of damp and fungal infestations, cracked walls, peeling paint, leaking roofs and water pipes, poor ventilation, overcrowding, widespread perceptions of local air pollution and bad odours in the neighbourhood, each of which is associated with ill-health conditions. In recognition of the powerful role of housing quality in health, the WHO recently updated its guidelines for healthy housing, especially in the light of climate change. [1] The new WHO housing and health guidelines build on earlier WHO guidelines on indoor air and water quality, for example, as well as on evidence emerging from the WHO CSDH, which emphasise the role of living conditions in health status. [16] A key question asked by the WHO CSDH was why we keep treating people only to send them back to the conditions that caused their ill health in the first place. This question is valid in respect of housing quality in Walmer Township and Wells Estate, and should be considered by local health, housing, trade and industry and financial sectors. A third layer of preventable environmental health vulnerability in Walmer Township and Wells Estate is brought to bear by planning decisions to locate human settlements in close proximity to point sources of pollution, in this case the Port Elizabeth airport and the Markman and Coega industrial areas . While detailed air, water and soil quality studies have not yet been undertaken in the study areas, significantly elevated perceptions of indoor dust and air pollution in Wells Estate should be heeded, and it is hoped will catalyse a proactive programme of investigation and concomitant intervention. Proximity to, or exposures from, sources of pollution are strongly associated with ill health, compromised quality of life and shortened life expectancy. Apart from noise, airports --- RESEARCH have been associated with the emission of pollutants such as carbon monoxide, particulate matter and black carbon, [17,18] as well as poor scores on assessments of subjective wellbeing among people living beneath the aircraft flight paths. [19] An SA study associated living in close proximity to an airport with elevations in hearing thresholds. [20] Given the very short distance between Walmer Township and the local airport, more comprehensive investigations of the health risks, including hearing and cardiac effects, associated with air pollution and noise are warranted. Holistic consideration of the findings of this study point to multiple lost oppor-tunities for the prevention of ill health, in terms of housing quality, poverty, livelihoods and the proximity of human settlements to point sources of pollution. Together with local health departments, non-health sectors such as urban planners, the human settlement sector, trade and industry, finance and the housing sector are in powerful positions to prevent ill health, in some instances in a more compelling and cost-effective manner than the health sector. Non-health sectors need to recognise that they are a health force to be reckoned with, and to take ownership of and exploit the opportunities they hold to prevent disease, save lives and build healthy communities, especially during this era of climate change. Failure to do so ultimately translates to potential acts of environmental injustice, heavy burdens of ill health among the most vulnerable in our unequal society, and a dimming of prospects of kick-starting the stagnant SA economy. --- Study limitations In this cross-sectional study, a snapshot has been provided of the situation at the time of fieldwork, and causal links between environmental exposures/living conditions and health status cannot be drawn. The sample size was relatively small, and the study findings cannot be extrapolated to other settings. --- RESEARCH --- Conclusions This study highlights the triple threat of socioenvironmental hazards faced by the communities of Walmer Township and Wells Estate: poverty; poor housing quality; and the lack of an effective buffer zone between human settlements and point sources of pollution associated with a range of harmful substances. These preventable environmental health hazards may be associated with a burden of ill health and mortality that is preventable, and in which regard non-health sectors, such as planners, housing departments, trade/industry and finance, have a powerful preventive role to play. Declaration. None.

Healthy housing is a fundamental pillar of good health in terms of its World Health Organization (WHO) definition as a state of complete physical, mental and social wellbeing, and not just the absence of disease. [1] Healthy housing is associated with 'a feeling of home' and also refers to the quality and role of the physical structure in enabling health, including aspects related to shelter from the elements, access to safe sources of energy and healthy indoor and ambient air, access to sufficient quantities of safe water, thermal comfort, absence of dampness and mould, and protection from pollutants, injury hazards and pests. Healthy housing also relates to local availability of education and health services, green space, active public transport options and protection from waste and pollution. [2] The location of housing in close proximity to sites of industrial pollution may cause preventable public exposure to pollutants in air, soil and water, with concomitantly elevated burdens of ill health, as indicated by numerous studies conducted in various parts of the world and in varying population groups. For example, a study undertaken in Oman showed that living close to an industrial park was associated with elevated levels of acute respiratory disease, asthma, conjunctivitis and dermatitis. [3] The risks of ill health were highest in older people and those of lower socioeconomic status. In Spain, living <2.5 km from certain industries has been associated with an excess risk of childhood leukaemia. [4] Researchers in Pueblo, Colorado (USA), have also shown that certain pollutant exposures may incur ill-health effects decades after the cessation of industrial activity. [5] Poor-quality housing, polluted living environments, and poor economic and social conditions (such as unemployment, uncertain employment and limited education) may independently exert detrimental health effects on affected communities. [6] In South Africa (SA), economic pressures underpinned by poor economic growth, high levels of unemployment, increasing consumer prices for energy and food, and household dependence on credit are some of the factors driving high levels of poverty. In 2015, >55% of South Africans were living in poverty, most of whom were black Africans, females, children, those with little or no education, and those living in Eastern Cape or Limpopo provinces. [7] Exposure to toxic substances in and around dwellings is a particular concern given the amount of time spent in the home environment. In well-resourced countries, people may spend ~70% of their time at home. In poorly resourced countries, where unemployment rates may be high and where relatively large proportions of households generate This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

INTRODUCTION The COVID-19 pandemic context brought inequalities to the forefront . Numerous international studies have measured the extent of inequalities associated with the COVID-19 pandemic . They reveal racial and ethnic , socioeconomic or territorial inequalities in mortality associated with COVID-19, including in France . Merging with pre-existing social inequalities, the COVID-19 pandemic further emphasized the global issue of social inequalities in health . Given this, the COVID-19 pandemic context could have provided a window of opportunity for acting on SIH. According to Kingdon, a window of opportunity is an opportune moment seized by political entrepreneurs, particularly during major events such as a pandemic, when it is possible to consider the implementation of a solution to tackle a major problem . Testing and contact tracing have been central interventions in the pandemic response. Different studies have shown the impact of social deprivation or ethnicity on the testing rate which was, except in certain cases, higher among socioeconomically privileged populations. In France, the spring 2020 lockdown policy also caused differential and cumulative effects on certain population groups . Public health interventions are likely to increase SIH if their design does not consider population needs . Two rapid reviews of the literature demonstrated that the consideration of SIH in the design of infectious diseases control interventions is typically rare . Interventions following the proportionate universalism principle are effective in limiting or reducing SIH from an equity perspective. The principle of proportionate universalism is that the intervention is implemented universally, for all, but that certain activities are specifically tailored to the particular needs of sub-groups of the population, taking into account the social gradient in the distribution of the health problem being addressed . To support stakeholders to better take equity into account, and in particular implementors, the Reflex-ISS tool was developed based on a review of the literature and applications in Canada . In France, testing and contact tracing interventions have been generalized as 'specific measures to control the epidemic risk' by the commission in charge of developing the national strategy for ending lockdown, which came into effect on 11 May 2020. Summarized by the three-step motto 'test, trace, isolate', the national strategy was based on: testing ; contact tracing ; isolation . This study aimed to analyze how SIH were considered in the design of SARS-CoV-2 testing and contact tracing interventions. --- METHOD --- Design We conducted a qualitative case study focusing on a pilot intervention that was part of COVID-19 response efforts in France. We focused on CoviTCT as it was one of the first interventions providing SARS-CoV-2 testing and contact tracing, as well as isolation assistance to the general population on the Île-de-France region . Initially carried out by the regional public hospital institution, the intervention design began in April 2020 and extended over the following weeks. The analysis focused on the period corresponding to the first and second waves of COVID-19 infections, from March to December 2020. --- Sampling strategy An exploratory phase consisting of a media articles review, gray literature review and analysis of available documents enabled us to identify the key actors of CoviTCT's design. Using a purposeful sampling strategy, we followed the principle of internal and external diversification . We reached an internal diversification by targeting a variety of actors involved in the design of CoviTCT in its central and local sites , which also reflected a form of diversification through their geographical locations and catchment areas. Actors from sites A and B were the primary target participants for the study given the focus on SIH. Site C was explored in less depth but included as part of our diversification strategy and also because it was closely linked to the central site of CoviTCT. Key actors involved in the broader governmental response to the pandemic were also interviewed to provide a better understanding of the general context in which CoviTCT was designed. We used a snowball strategy for participant recruitment over the course of the study. --- Data collection Between November 2020 and May 2021, we collected a variety of press content, gray literature and documents . Between December 2020 and May 2021, the first author conducted semi-structured interviews, averaging 40 min in length, until the point of empirical saturation. At times, the interviews were conducted with the second and last authors. We interviewed 21 women and 15 men of all ages who were mostly health care workers, often key actors in the central and local sites . We also interviewed public health professionals from diverse public agencies, humanitarian professionals, members of civil society's organizations among others . The interviews were conducted following a conceptual framework providing three planning dimensions with respect to SIH: Reflex-ISS . In an equity perspective, this health promotion tool intends to facilitate the consideration of SIH in each stage of public health interventions . Our research focuses on the first stage, identified as design, of a public health intervention. Beyond the focus on SIH, interviews also included an open discussion regarding their trajectory, how they perceived their work, or their thoughts regarding the pandemic and SIH. We contacted 53 individuals via email, phone or LinkedIn messages. We carried out 33 interviews between the 11 November 2020 and 24 April 2021, 19 of whom were involved in the design of CoviTCT . Due to the pandemic context, 23 interviews were conducted remotely and 10 in-person. Given their active involvement with the pandemic, many of them had limited time and mental availability. Three of the respondents were met with twice as they had to end the first interview due to professional commitments. The use of videoconference and phone calls to conduct remote interviews allowed for flexible adjustment to respondents' schedules , despite the technical challenges and the difficulty of collecting non-verbal data . These interviews were audio recorded and fully transcribed. --- Analytical strategy The consistency of the findings was checked by data triangulation. We applied an inductive-deductive analysis strategy. As part of the inductive analysis, interview transcriptions were read multiple times and annotated to reflect the words of participants. This inductive analysis fostered the emergence of original elements with regards to sociological profile and trajectory of the respondents, their discourses and representations. As part of the deductive analysis strategy, the dataset was processed by MaxQDA software. The themes emerging from the inductive analysis were regrouped around the three dimensions of intervention planning according to Reflex-ISS: problems and needs analysis; objectives, rationale and design of the intervention; cross-sectoral partnerships and participation of the target population . In the next section, the results are presented following the deductive structure of our analysis, in the order of the three dimensions of intervention planning of Reflex-ISS. The titles reflect the main elements that emerged inductively in each of these dimensions. --- RESULTS Tackling SIH in the context of an outbreak: emergency and ambivalences SIH taking a back seat to the health emergency Despite respondents' intense workload due to the pandemic response at the time of the interviews, they made themselves available and demonstrated concern for SIH. However, SIH were rarely mentioned spontaneously by the respondents despite the explicit mention of our questioning, and none of the reviewed documents mentioned SIH. The urgency of the pandemic situation appeared to be the main concern, which resulted in narratives of haste and positive tension that seemed to inhibit critical reflection. In most of the discussion, consideration of SIH appeared to be secondary, sometimes as inappropriate, as if urgency had overshadowed the SIH challenges. For instance, a general practitioner stated that the health crisis context was incompatible with action that was proportionate to the needs of population sub-groups. --- Behind diverse perceptions of SIH: the specters of poverty and exclusion The interviews revealed the diverse representations of SIH in participants' responses. Migrant populations, particularly those living in collective accommodations, appeared as the prevailing representation for SIH, regardless of the actors' professional background. Rather than discussing SIH, participants more often focused on populations in situations of poverty and/ or social exclusion. They frequently used an interchangeable vocabulary: populations 'in a vulnerable situation', 'in difficulty' or 'in a precarious situation'. At times, some actors asked about the meaning of 'social inequalities in health', suggesting that this topic remained confusing within the medical and humanitarian health fields. The actors had different perceptions of SIH which appeared to be related with factors such as their domain of expertise, location of usual professional activities and epidemic response experience. The actors' comprehension of SIH can be situated on a continuum ranging from a biomedical to a health promotion vision . Private medicine professionals expressed more a biomedical vision. Public medicine professionals or humanitarian professionals tended to focus more on a health promotion vision of SIH, as well as public health professionals. Regarding the location, professionals working in central Paris mostly demonstrated a biomedical comprehension of SIH, while professionals acting in the north suburb of Paris and specific popular or priority neighborhoods showed a more health promotion comprehension of SIH. Lastly, actors having a significant epidemic response experience , expressed a health promotion vision of SIH. Actors that had a little or no experience in the epidemic response focused more on a biomedical understanding of SIH. --- A consensus: the unequal dimension of the pandemic Respondents agreed on the unequal dimension of the COVID-19 pandemic. For several participants, this could be linked to a humanitarian sensitivity and experience. Various participants also expressed a keen interest in public health issues, and/or their concern for inequities resulting from field experience in COVID-19 response efforts. All respondents agreed that different socioeconomic factors may increase the vulnerability of some populations to the risk of infection of SARS-CoV-2. Most participants identified different attributes of housing as factors that increase the risk of infection. They mentioned the likelihood of increased virus transmission among the household members and barriers to certain control and prevention measures . They also pointed out financial insecurity as preventing access to personal protective equipment. A few participants mentioned barriers arising from language and health literacy challenges in terms of understanding the purpose and directions of the different control and prevention measures. --- The challenging operationalization of addressing SIH during a health crisis Biomedical epidemiology framework, pragmatism and adaptations in a context of urgency The design of CoviTCT began in April 2020. It took place in a context of scientific uncertainty regarding the virus and its modes of transmission, in addition to a scarcity of testing given material and resource constraints. Anticipating the gradual ending of the lockdown restrictions and increased transmission, a hospital physician with specialization in infectious and tropical diseases with extensive humanitarian experience, led efforts to organize teams that would visit potential patients' homes for testing and counseling. It resulted in the transfer of a model previously implemented in Haïti for the cholera epidemic. The primary objective of the intervention was to 'break the chains of transmission' [Slideshow: presentation , partners meeting of 14 April 2020] by implementing a case targeted intervention intended for the general population of the Île-de-France region. This strategy called for the deployment of the intervention around confirmed and suspected cases of COVID-19. The first stage, detection, illustrates the strength of the epidemiological argument and the central position of the virus in the strategy: the intervention was based on transmission hotspots. When a hotspot was confirmed, the intervention of field teams were then deployed for mass testing with the objective of controlling its spread . Such a detection strategy appeared to be at odds with a SIH reduction approach: 'I had put forward proposals, as I said about the mobile units, to reach the most vulnerable groups in order to re-establish certain inequalities and to reach the groups that were not going to access the system. [...] I think my proposal was perhaps a little surprising and then what I understood was that it didn't work like that, so they didn't see how it was going to be done. It was, for them I think my suggestion was a bit abstract'.-CoviTCT partner, AIDS non-profit organization Yet, actors involved in the first stages of CoviTCT's design said their intent was to differ from the criticized top-down, uniform and coercive governmental response strategies to the epidemic implemented at the time . The proposal was designed as 'pragmatic', trust-based and 'contextualized'. CoviTCT included a social component aimed at making this strategy compatible with a diversity of social situations and therefore improving its acceptability. Mobile teams were rolled out to conduct home visits. They were responsible for testing at home, delivering a kit consisting of masks and hydroalcoholic gel, and fostering a partnership with the COVID-19 cases to identify and organize their isolation plan based on an assessment of their living environment. As it turned out to be necessary in some cases, they could resort to humanitarian or local social services to provide some social support during the period of isolation. While the medical provision standard of CoviTCT was clearly defined, the design of the intervention left room for a significant amount of improvisation. This was especially true with regards to the social component, which was associated with the ability of the field teams to adapt and improvise, which were less discussed and formalized. 'We adapted completely to this family context and with that, our team improvised in some ways, so they had their baselines for isolation, they had their baselines for advice and procedures to follow up on transmission and to make sure that it was cut off as quickly as possible and therefore, to isolate this outbreak. And so, as a result, they were improvising according to the contexts'.-Project team member The centralized design of CoviTCT made it possible to provide a general framework that was common across all sites. Due to the urgency of the situation in terms of time and health risks, CoviTCT became active in less than a week after the beginning of its planning. The process was refined through the experimentation of different models, that was done concurrently during its implementation. The local sites developed and experimented with an operational model that was adapted to their context, which resulted in important differences between the sites in terms of how SIH were considered. --- Diversity of attempts and approaches to addressing SIH in the intervention There were important differences between the Parisian sites and suburban site regarding the way SIH were considered in the design of their respective operational models. This may be related to the socio-economic contrast of the territories with the most deprived to the wealthiest . Initially focused on home visits, the local site A opened a testing center in October 2020, although this required a doctor's referral until December 2020. After this date, the site's team the team bypassed these restrictions and encouraged mass testing of the population before possible holiday gatherings. In keeping with a medical vision of caregiver-care receiver relationship, trust was emphasized as the main factor of adherence to the intervention at this site. Interestingly, it was not always recognized that socio-economic determinants could be an issue regarding intervention implementation. 'I think that a fairly simple [public health intervention] model, everyone adheres to it. And it's not because it's a person in a more precarious situation that they won't adhere to it. What works is that people trust us. [...] It makes no difference whether they are in a precarious position or not'. General physician, local site A Conversely, the former coordinator of local suburban site B outlined the team's 'real desire to get closer to the people and to reach a population that is particularly vulnerable in comparison with private urban medicine'. As COVID-19 cases were frequently refusing home visits, the operational model of this site was quickly adapted. To foster improved accessibility and acceptability of the intervention, a testing and contact tracing alternative was developed in various centers within a municipal health network, urban private practices and a local public hospital. Patients could present without an appointment, unlike in sites A and C. The actors involved in the design of the model of site B demonstrated a critical reflection on CoviTCT and their own action regarding SIH. During his interview, the initiator of site B pointed out a 'very clear lack of perception of deprivation in the department' among the team that designed CoviTCT's centralized outline. He insisted on the need to adapt the intervention model to the socioeconomic local context. Another team member regretted the non-use of proportionate-universalism approaches and stated that: 'Basically [CoviTCT], while having noted and followed a logic that was a little bit different […] doesn't replace some 20 to 30 years of history of public health in France'. General and public health physician, local site B --- Cross-sectoral 'partnerships' during a health crisis: between distrust and collaboration From hypercentralization to the multiplication of actors At the very beginning of the outbreak, CoviTCT's design was characterized by its hypercentralization. The general approach of the intervention was first designed by a few influencial members of the regional public hospital institution, following which a variety of actors from different sectors became gradually involved. The implementation of the intervention was made possible by the massive mobilization of volunteers, including several hundred students and young professionals. Most of the volunteers joined the field teams after a theoretical training on interculturality, motivational interviewing and non-judgmental attitude. The training was developed by an association dedicated to fighting HIV/AIDS with extensive experience in addressing SIH. The COVID-19 cases' participation in the intervention took the form of a partnership between cases and field teams, nurtured by a relationship based on trust. Case participation remained limited to the interaction with field teams as part of the contact tracing process or organization of isolation, with no involvement of the cases in the design of the intervention itself. The profiles of the actors varied depending on the sites. The influence of the initiator of each site appeared to be instrumental in the mobilization of actors, as well as the presence of networks that existed before the pandemic. The public hospital doctor who initiated CoviTCT gathered former humanitarian colleagues, as well as hospital colleagues. Over time and following the intention not to adopt a hospital-centered approach, CoviTCT was increasingly taken over by physicians practicing private medicine in urban centers. In sites A and C, the private general practitioners who initiated the sites mobilized the local multi-professional health communities. As a result, both sites relied on the involvement of a majority of private medical and paramedical health professionals. The public hospital doctor who initiated site B relied on public municipal and territorial health network. In this more deprived territory, this network was already mobilized for other infectious diseases . Consequently, the main actors involved were municipal health actors, hospital professionals as well as urban private medical professionals who were mobilized via their representative organization. A similar expansion dynamic was observed with regards to the organizations known as 'partners' of the intervention. Local public services, as well as CSOs were involved according to needs. The summer of 2020 was also associated with the increase, in number and power, of key actors involved in the deployment of testing and contact tracing government strategies. This dynamic brought together many intersectoral partners including medical NGOs and CSOs, municipalities, public social and/or health services. Participants appreciated this multi-actor and decentralized collaboration, as it was considered a valuable opportunity to try an alternative governance structure, different to the traditional silos of the health system. Respondents also emphasized the complexities of bringing cross-sectoral partnerships to fruition due to chronic resource shortages, power imbalances and persistent misunderstandings between the partners, including SIH. --- Complexities of cross-sectoral partnerships Respondents mentioned various barriers to mobilizing cross-sectoral partners. Despite their attempts, the North Paris team was unable to mobilize social workers due to a lack of human resources, administrative complexities and fears related to the pandemic situation. While other examples of mobilization of cross-sectoral collaborations have proven successful, the equitable dimension of the collaborations is questionable. Not all actors held the same position within the intervention. Professionals from the medical or paramedical fields were predominant in the intervention design. On the contrary, other actors, such as CSOs and social workers, mainly focused on operational aspects , and were often excluded in the design or planning stages of the intervention. Lastly, there were important differences in understanding and the vision of SIH between different professions. For example, between private medical practice and public hospital medicine: We had set up this [local site B] as a purely public health operation, the financial dimension did not interest me and did not catch my attention. And I faced this first thing which was that the private general practitioners […] wanted guarantees that their patients would not escape them. Like it was not normal for patients seen in a private practice to be cared in a municipal health center. And I fell off my chair because I thought, 'How can such considerations arise while we are in the middle of a health crisis and people are dropping like flies'-Hospital infectious diseases specialist, local site B However, these divergences did not prevent valuable collaborations. The collaborations experienced between hospital medicine and private urban medicine were regularly mentioned in participants' discourse as one of the successes of CoviTCT. In contrast, they shared more reserved opinions on certain collaborations, such as those between the medical and public health sectors in certain respects. Forms of diffidence and misunderstanding persisted at the expense of addressing SIH. For instance, a general physician of local site A contested the scientific basis and refused to take part in an intervention addressing SIH promoted by a regional public health institution: The difficulty is that I never knew how [the interventions in priority neighborhoods were] done. Was it done on a scientific basis or on a political basis? Downloaded from https://academic.oup.com/heapro/article/38/1/daac173/6974796 by guest on 07 May 2024 Because it is a priority district of the city and we see that it is necessary to go and do it there to show that people are not forgotten? Political.-General physician, local site A --- DISCUSSION --- Critical insights on the consideration of SIH in designing CoviTCT and COVID-19 response efforts This case study highlighted some of the challenges of addressing SIH in the design of COVID-19 response efforts in the Île-de-France region, France . Findings revealed diverse understanding and visions of SIH among CoviTCT's actors, as well as the complexities of mobilization and cross-sectoral partnerships. CoviTCT was rooted in and took place in a context of an organizational crisis of a 'weak' French public health system , and a rapidly changing and uncertain COVID-19 environment . Our findings emphasized an intervention design relying on the mobilization of existing configurations of actors, strategic and operational models: a phenomenon widely observed in decision-making processes in crisis contexts . The urgency to act without delay rushed the design process and led to its initial centralization around medical and paramedical professionals. The intervention design was similar to the general dynamics of the pandemic response in France. The lack of pandemic preparedness resulted in an overrepresentation of medical elites compared to public health professionals and institutions . There was little room for co-creation or the structuring of collective action around the consideration of SIH in the design of the intervention. The actors faced widespread challenges in the design of public health interventions such as power inequities and difficulties regarding intersectoral action . Among CoviTCT's actors, SIH was mostly related to situations of great poverty or exclusion, notably migrant populations, at the extreme end of the social gradient in health which correlates position in the social hierarchy with health condition of individuals. These findings reflect the challenges associated with the historic lack of understanding of social determinants of health and SIH within the French healthcare system . Medical training and the professional culture often overlook these concepts and has previously raised concerns about continued discrimination . The analysis of public policies invites us to dwell on the representations of the problem and problematization . Initially designed and implemented to address a severe medical humanitarian emergency in Haiti, the intervention was urgently transferred to France to fight against COVID-19 despite the differences regarding the diseases and national contexts. For Ridde and Guichard, 'the way in which the causes of health inequalities are understood and socially constructed will influence not only the decision to take action but also the methods of action' . This translocation highlights CoviTCT's links with humanitarian approaches, social medicine and social epidemiology all widely developed in southern countries. Even so, centered on the virus and contaminations, around the COVID-19 positive patients, the model of CoviTCT participated in producing a predominant clinical framing of the pandemic situation. The similar intervention deployed to fight cholera in Haiti was considered to have a predominantly biomedical public health approach . In CoviTCT, when there was consideration for SIH, it was as an element complementing the clinical epidemiology strategy of the intervention and supporting its --- Problems and needs analysis • Despite an important concern for the unequal dimensions of the pandemic, inequalities appeared secondary to the pandemic emergency. • CoviTCT's actors did not share a consensual understanding of SIH, which were often equated to poverty and social exclusion. Objectives, rationale and design of the intervention • CoviTCT's design planning was expedited by the health emergency. • CoviTCT was based on a biomedical epidemiological approach which prevailed during the intervention design. • The social component of the intervention supported its clinical activities by addressing certain inequalities. • The approach to address SIH took different forms depending on the site of the intervention. --- Cross-sectoral partnerships and participation of the target population • Actors from the medical fields designed CoviTCT. Despite the focus on Paris for this case study, these findings echo that of the broader response to the COVID-19 pandemic globally. Health promotion and its objective of reducing SIH appeared to have been mostly neglected . Our use of the Reflex-ISS tool and a public policy analysis approach emphasized that, while the pandemic was the occasion for a 'rediscovery' of the SIH issue , it did not constitute a window of opportunity favorable for their consideration. Our findings have highlighted the need to improve the understanding and working on SIH during 'routine' periods. It appeared paramount to promote SIH consideration in crisis situations, when standard operating procedures take precedence . Recent innovations such as the plan to fight SIH adopted by the Île-de-France regional health agency show that in the pandemic context, SIH have become the major priority for action within certain public health institutions. The COVID-19 crisis has not only demonstrated that a collective and formalized fight against SIH was crucial, but also that it was possible. --- Investigating SIH consideration in intervention design: strengths and limitations Our investigation provides methodological and theoretical insights on the use of Reflex-ISS as a research tool in health promotion research in the COVID-19 pandemic context. The use of the Reflex-ISS tool as a basis for data collection made it possible to focus the interviews on elements directly related to CoviTCT's design and on the consideration of SIH. Participants' tendency to focus on action narratives not centered on SIH suggested that this approach may be preferable in crisis situations. However, the semi-structured interviews based on Reflex-ISS constrained the participants' discourse while the pandemic context was not optimal for reflective considerations on the design of emergency interventions. It sometimes put respondents in an uncomfortable position by urging them to focus on topics or aspects that appeared difficult to grasp in a health crisis situation. Also, the design and implementation appeared to be intertwined in the context of COVID-19 outbreak and difficult to distinguish at the operational level. From this standpoint, the temporality of our investigation also represented a limitation. It began in September 2020 to June 2021, several months after the initial design we were investigating. The initial design was likely subject to poor recall for various key respondents, given the time delay from when they were interviewed to the time period of interest. These different points highlight the importance of using an analytical approach with an inductive dimension. Our hybrid approach to analysis enabled us to complete the deduction based on the Reflex-ISS tool. If we had limited ourselves to the components of the Reflex-ISS tool , our analysis would have emphasized negative aspects . The inductive analysis made it possible to analyze the rich empirical material in the respondents' own words and provide more nuance on respondents' accounts and understanding of SIH. For instance, it allowed us to perceive the staggering urgency weighing on the actors; the clinical framing of the pandemic among the actors; or the determinants of the barriers to consideration of SIH in the design of the intervention. From an epistemic point of view, this allowed the Reflex-ISS framework to be mobilized as a conceptual framework versus a normative framework. Lastly, the discussion of these results from public health and political science perspectives fostered a holistic understanding of the design process which is not only the result of individual decisions. This approach made it possible to consider the pandemic conjuncture and, at a broader scale, structural sociopolitical dynamics that influenced CoviTCT's design. --- CONCLUSION Our research emphasized the numerous challenges of tackling SIH in context of the COVID-19 pandemic. A collective vision and intersectoral action against SIH did not occur during the initial design of CoviTCT, and instead, a biomedical approach prevailed . This biomedical approach to public health interventions and the omission of SIH in the initial design has been common in France . Positioning a SIH reduction approach as a complement to dominant biomedical strategies can mitigate some of the inequitable effects of an intervention. However, it will be insufficient to address their systemic and structural nature. The experience of the COVID-19 pandemic highlights the crucial need of promoting and formalizing SIH reduction approaches. Socio-environmental developments suggest that pandemic events will increase in the coming years. From a dual perspective of social justice and epidemiological coherence, the COVID-19 pandemic has highlighted that SIH need to be considered as the basis of infectious diseases response, regardless of the emergency context. --- CONFLICT OF INTEREST The authors declare that they have no conflict of interest regarding the research, authorship and publication of this article. --- ETHICS APPROVAL The 'Comité d'Évaluation de l'Ethique des projets de Recherche Biomédicale Paris Nord' has reviewed and approved the research project in 2020.

The COVID-19 pandemic highlighted the impact of social inequalities in health (SIH). Various studies have shown significant inequalities in mortality and morbidity associated with COVID-19 and the influence of social determinants of health. The objective of this qualitative case study was to analyze the consideration of SIH in the design of two key COVID-19 prevention and control interventions in France: testing and contact tracing. Interviews were conducted with 36 key informants involved in the design of the intervention and/or the government response to the pandemic as well as relevant documents (n = 15) were reviewed. We applied data triangulation and a hybrid deductive and inductive analysis to analyze the data. Findings revealed the divergent understandings and perspectives about SIH, as well as the challenges associated with consideration for these at the beginning stages of the pandemic. Despite a shared concern for SIH between the participants, an epidemiological frame of reference dominated the design of the intervention. It resulted in a model in which consideration for SIH appeared as a complement, with a clinical goal of the intervention: breaking the chain of COVID-19 transmission. Although the COVID-19 health crisis highlighted the importance of SIH, it did not appear to be an opportunity to further their consideration in response efforts. This article provides original insights into consideration for SIH in the design of testing and contact-tracing interventions based upon a qualitative investigation.

INTRODUCTION Childbirth and birth are phenomena that undergo modifications according to the society in which they are inserted. The current obstetric scenario reflects an institutionalization of practical knowledge associated with childbirth and invasive procedures, often unnecessary and potentially iatrogenic, resulting in the loss of women's autonomy . This process is called medicalization. The routine performance of c-sections causes the isolation of pregnant women and their families, negatively interferes in newborn care, and puts the maternal and fetal health at risks, becoming an abusive procedure and hindering the adoption of humanization conducts in this process. Women are subject to strict and mechanized routines that are adopted without critical evaluation on a case-by-case basis . Therefore, the high number of c-sections can cause more harm than good to mothers and the fetuses. Concerning the c-sections performed in the Brazilian Unified Health System , there was an increase from 38.3% in 2001 to 55.15% in 2014 . From such index, we infer that Brazil lives an epidemic of elective c-sections. Hence, considering the medicalization aspects of the Brazilian obstetric care and its development, such as high rates of c-sections and the circulation of collective discourses of risk in the pregnant-puerperal cycle, we aim to reflect on the process of medicalization of childbirth and its consequences, from a Brazilian audiovisual media artifact. The documentary O Renascimento do Parto portrays this period of late modernity, in which such practices result in turning women into frail and incapable parturients, believing they need aid to achieve the birth of their child, denying their own capacity to give birth and decreasing their potential . This reflection is justified because vital events, such as the birth, are based on a model centered in medical technology, favoring the emergence of a c-section culture, in which common symptoms or ordinary factors become the reason for choosing the surgical procedure. Childbirth assistance in Brazil is still characterized by procedural attitudes supported by cultural changes, and convenient interventions are imposed to knowledge and practices established by the biomedical field. Therefore, we focus on the formation of social and discursive practices concerning this late modernity, in order to contribute to a more complex vision of births. --- OBJECTIVE To reflect on the medicalization process of childbirth and its consequences, from a Brazilian audiovisual media artifact. --- METHOD This is a reflective and interpretive analysis based on the documentary O Renascimento do Parto. To this end, data are presented for the production and construction of our narrative, being analyzed its content by two analytical categories: Giving birth to life: from nature to medicalization; Between perceptions and affections: where are the love hormones? In such categories were used excerpts from interviews in the documentary that support and illustrate their central ideas. This study analyzes discursive practices for establishing identities of the professionals and the pregnant women within the current obstetric scenario. The best way to analyze an audiovisual material is choosing a theoretical framework and applying it to the empirical object. Hence, our analysis was based on Critical Discourse Analysis . The theoretical and methodological assumptions of CDA, formulated and presented considering the concepts of the British linguist Norman Fairclough , will be useful to create this framework of statements present in the documentary. The following step was selecting a sampling framework, which would be the medicalization of childbirth, and then creating rules for the transcription of visual and verbal information, selecting illustrative citations that would complement the visual analysis. To do so, were considered three essential elements in discourse analysis: production, in the case of the documentary, highlighting its authors, producers, and other contributors; the text itself; and the reception regarding the interpretation by those who watch the documentary. For a production to make sense, it is not necessary for it to be within the text; it can be what "has not been said." Thus, it is possible to identify its assumptions . The documentary is a Brazilian production that addresses, as a public accusation, the increase of c-sections in Brazil and which stands for the autonomy of women during childbirth. The movie lasts 90 minutes and it was directed by Eduardo Chauvet, screenplay by Érica de Paula, photography by Rafael Morbeck, and soundtrack by Charles Torres and Marcello Dalla. It was released in August 2013 in Brazil and features statements ranging from personal experiences to results of scientific research. Among the interviewees, we highlight the participation of Michel Odent , Robbie Davis-Floyd , Daphne Rattner , Naoli Vinaver , and the Brazilian couple Márcio Garcia and Andréa Santa Rosa . In addition, Brazilian doctors/obstetricians, pediatricians, nurses, doulas, midwives, and women with maternal experiences both positive and negative participated in the documentary. Considering the speeches, participants contributed positively reporting the historical process of transformation of this paradigm, when the birth art, for a long period, was classified as an exclusively female function. Giving birth to life: from nature to medicalization The categories were classified as elements, since according to CDA social life is composed of social practices in constant and unstable articulation, thus considering discourse as an element of these practices. The first category was described as element 1, in which childbirth was chosen as an example of a material activity. During the Middle Ages, labor was perceived as the main role of women, and religious decrees forbade the male presence within the giving birth scenario, making it an activity exclusively feminine. Initially, parturient women received empirical care from women who were considered to be witches and those who were curious. However, over time, this kind of behavior has been modified by man. The male figure appears in the history of childbirth by introducing obstetrics as a science, implementing the horizontal delivery and episiotomy . From the consolidation of hospital delivery, the medicalization of this event resulted in the loss of women's autonomy as bellwether of the giving-birth process, leaving this physiological and vital event to be marked by the overuse of invasive practices, often unnecessary and potentially iatrogenic . These conditions ended up resulting in oppression situations, whether due to the medicalization of the female body or the non-recognition of women's protagonism in this process. "We can't give birth the way our mothers and grandmothers did. We can't do what once was considered normal!". . In such speech, the interviewee begins her report in the present tense, promoting the idea of women's inability to act when giving birth, especially when stating "we can't do what once was considered normal." This idea, along with the phrase "We can't give birth the way our mothers and grandmothers did," illustrates the order of discourse of change in the obstetric reality and women's appropriation in their own labor. The transfer of the birth environment improved health indicators in Brazil, especially concerning the reduction of maternal and neonatal mortality rates over the past thirty years . In ideal conditions, the c-section is safe and contributes to reducing maternal and perinatal morbidity and mortality, hence its value in modern obstetrics. However, the negative consequence was the increase in the number of interventions at birth without justified medical reasons. In this sense, the World Health Organization states that rates above the range of 10 to 15% do not contribute to reducing maternal, perinatal, or neonatal mortality. In the Brazilian context, in which there is a high rate of already-performed c-sections, the reference rate is estimated around 29% . It is noteworthy that the counterproductive feature induced by the elective c-section, understood as the imbalance between autonomous health actions, such as products of the interaction of the individual with the social environment, and heteronomous health actions, undertake by health professionals and specialists within the institutionalization context, results in an illusion of needing more heteronomous actions for correcting undesirable and potentially harmful consequences, transforming this reality in a vicious circle. "Women ended up conforming to strict standards established by the medical system according to which they must give birth in a given time and behave in a certain way". . In the second speech, the doctor describes the female resilience, mentioning the conformation and consequent adaptation of women to medicalized acts, without expecting a justification for such action. At the same time, in his speech the doctor blames the public system, when stating that women "must give birth in a given time and behave in a certain way." Standardization of the labor process is a structural condition of late modernity, which equals people and situations in conditions of economic, social, and cultural inequality. Therefore, a consumption need is produced, conditioned by professional interests that culminate in an identification on the part of some women. C-section ends up being the result of a cultural and social medicalization. In this sense, the public system itself, the reality of the health situation in our country, and the obstetric care model contribute to such results. --- "There is a cultural logic on top of that. […] The patient has the idea that the c-section is more controlled, less risky, or with no risk at all. And that her baby will be safe. The doctor, on the other hand, despite having learned that natural childbirth is safe, that is good for the baby, ends up believing in the false fact that c-section is safer". . The expectation of a "safe delivery" is associated with the "tranquility" of a c-section. The doctor describes such attitude when stating that women believe "c-section is more controlled, less risky, or with no risk at all." Thus, the last two statements may be representative of the power of medicine and the feeling of non-participation of women in an act that once was natural. The idea of greater control in the c-section is established by elements of the surgical technique which require greater knowledge and professional skill, instituting a power-knowledge path. In addition, there is the possibility of controlling variables, such as time, which allows increasing productivity. However, the little time directed to women's care may negatively reverberate to the establishment of the professional-patient bond. Such bond is surrounded by affections, and these may generate comfort and delight. In a counter-hegemonic way, professionals working in obstetric care, especially doctors and nurses who are interest in restoring the vaginal delivery, work with evidence-based health practices, in order to reduce the trivialization of this type of procedure. However, it is still a paradigm to be overcome and a challenge, since medicalization has been established by diverse strategies, using different actors, including the state mediation. The result was the exclusion of women from their traditional practices, an issue that is discussed by the movement of humanization of labor and birth. Between perceptions and affections: where are the love hormones? The second category represents the mental phenomena. Overall, they concern feelings, beliefs, and values. For this reason, the hormonal cocktail produced by women during labor was chosen to represent the element 2. During labor, women are physiologically prepared for the upcoming release of hormones that are programmed to act before, during, and after the child's birth and that influence the behavior and bond between mother and son, which may have an impact even on the ability to love and on people's potential aggression. Unnecessary c-section prevents the production of the hormonal cocktail, which has oxytocin as the main secreted substance. During labor, such hormone triggers contractions that precede it, performing many functions that are beneficial for both the mother and the newborn. In addition, oxytocin is also produced during sexual activity, being responsible for male and female orgasms, and when breastfeeding . "Until recently, love was the theme of poets, philosophers, and novelists. But today, love is also studied by scientists. Nowadays we understand that the ability to love is largely organized and built during the period comprising the birth". . The obstetrician Michael Odent describes this hormonal production as a feeling. When he says "the ability to love is largely organized and built during the period comprising the birth," he narrates the importance of creating the bond between the binomial mother/son. These hormones produced at childbirth will favor the development of the bond, thus avoiding possible complications and making maternal recovery faster . In addition to physiological aspects, the birth organizes and builds our capacity to love; the labor period has potential for achieving this goal, as well as it allows developing the female body awareness and relationships with the people that are meaningful, which reflects on the strengthening of affective bonds. "Labor is not only a physiological act that begins with contractions and ends with pushing the baby and the placenta out. It is, above all, a true rite of initiation, of passage, not only for the mother, but also for the whole family and the baby that actively participates in this experience and come out of it stronger". "People think that giving birth is a bodily thing. […] A physical thing only. But... over the years that I monitor labor processes, I see that it is the soul of the woman expressing itself through the body". . Some doulas also participated in the documentary, and their speeches express the subjective side of childbirth. One of them evidenced this when saying that giving birth is "above all, a true rite of initiation, of passage," making it clear that the experience of this moment makes women more assured of their emotional capacity. The giving-birth process provides women the transcendence of boundaries, connecting them with their inner I to the extent it promotes the expression of their soul through the body. Labor as a rite of initiation is based on the premise that, with it, a mother, a child, a father, and a family are born -an event that establishes a multiple-implication relationship that, when positively experienced, is able to generate happiness and to strengthen the affective and social relations. C-section radically separates the newborn, the placenta, and the mother from each other. The coldness situation worsens with the absence of love hormones. Elective c-sections prevent the labor process and, consequently, the action of hormones essential for childbirth and for strengthening the creation of the bond between mother and son. To the profile of the c-section incidence decreases, some aspects are required: to restore the protagonism of women at the labor process; integrative and comprehensive vision of the phenomenon, involving psychological, affective, emotional, spiritual, cultural, and contextual aspects in which the labor takes place . Updating our way of thinking with new theories of thought will provide a new worldview, in which the separation would be replaced by the interrelationship and integration of all physical, biological, psychological, social, political, and cultural phenomena . We should raise awareness about the cultural process in which we are inserted, process which has the potential to produce a broader thinking, able to fulfill our need to know, given our need to want and our freedom to feel, representing, therefore, the way amid this fragmented culture. --- Study limitations The scope of two thematic categories. Contributions to the field of nursing, health, or public policy Indicating CDA as an element to understand the social phenomena that relate to medicalization of obstetric care in Brazil is essential to the professional ethos of nursing. This understanding is essential to comprehend that the role of the nurse midwife in the childbirth care decreases unnecessary interventions, which reflects on the reduction of the rates of c-sections, the increase of women's protagonism, and the respect concerning the physiological, emotional, and social dimensions within the giving birth/being born process. --- FINAL CONSIDERATIONS Childbirth is established as a material element and a mental phenomenon of social practices. Therefore, it is polysemic and subject to interventions, especially when health is guided by a hegemonic biomedical model, which produces medicalization of vital events. This process has as consequences the increase of medical intervention in labor and birth, which in Brazil is reflected on the increase in c-section rates beyond what is considered acceptable by international public organs and on the loss of women's autonomy. Hence, we acquired a knowledge that standardizes behaviors, disciplines bodies, and controls the physiological events that are inherent in life. However, the body is not linear, but complex; there are physiological events which are culturally meaningful to express its creative potential. Oxytocin, understood as the hormone of love and delight, is produced during labor and causes pain, which is inherent in life, but which promotes and encourages the labor process and, therefore, increases the potential to generate happiness. In order to the "rebirth" of childbirth takes place, it is necessary to interrupt this hegemonic model of obstetric care in Brazil; to allow the body, during parturition and as physiological and cultural unit, to express itself through the release of oxytocin; to decrease the segregation between mother and son that the c-section causes and restore women's autonomy, improving the creation of affective bonds between patients, the newborn, family, and healthcare professionals, making this vital event less negative and considering the complex understanding that such is part of the sexual, emotional, and social life of women.

Objective: to refl ect on the medicalization process of childbirth and birth and its consequences based on a Brazilian audiovisual media artifact. Method: refl ective and interpretive analysis of the documentary O Renascimento do Parto (The Rebirth of Childbirth) based on Critical Discourse Analysis. Results: c-section emerges as an alternative to adverse conditions of pregnancy. However, it has become a routine and abusive practice of a medicalized obstetric care, thus becoming a social problem. In order to the incidence of c-sections decrease, women's protagonism must be restored, in addition to considering psychological, affective, emotional, spiritual, cultural, and contextual aspects in childbirth. Conclusion: childbirth is established as a material element and a mental phenomenon of social practices. We must interrupt the predominant model, allowing the body to express itself through the release of oxytocin, and decrease the segregation that c-section causes, thus enabling affective bonds. Descriptors: Childbirth; Natural Childbirth; Medicalization; Obstetrics; Doulas. RESUMO Objetivo: refl etir sobre o processo de medicalização ao parto e nascimento e suas consequências, a partir de um artefato midiático audiovisual brasileiro. Método: análise refl exiva e interpretativa do documentário "O Renascimento do Parto", baseada na Análise do Discurso Crítica. Resultados: a cesariana confi gura-se como alternativa para condições adversas gestacionais. Entretanto, tornou-se uma prática rotineira e abusiva, de uma atenção obstétrica medicalizada, passando a ser um problema social. Para que a incidência de cesarianas diminua é necessário que seja restituído o protagonismo da mulher, além de considerar aspectos psicológicos, afetivos, emocionais, espirituais, culturais e contextuais no parto. Conclusão: o parto confi gura-se como elemento material e fenômeno mental das práticas sociais. É necessário romper com o modelo predominante, permitir que o corpo se expresse por meio da liberação de ocitocina e diminuir a segregação que a cesariana provoca, proporcionando a formação de vínculos afetivos. Descritores: Parto; Parto Natural; Medicalização; Obstetrícia; Doulas.Objetivo: refl exionar sobre el proceso de medicalización al parto y nacimiento y sus consecuencias, a partir de un artefacto mediático audiovisual brasileño. Método: análisis refl exivo e interpretativo del documental "O Renascimento do Parto", basado en el Análisis Crítico del Discurso. Resultados: la cesárea se confi gura como alternativa a condiciones adversas en la gestación. Sin embargo, se convirtió en una práctica rutinaria y abusiva, de una atención obstétrica medicalizada, pasando a ser un problema social. Para que la incidencia de cesáreas disminuya es necesario que sea restituido el protagonismo de la mujer, además de considerar aspectos psicológicos, afectivos, emocionales, espirituales, culturales y contextuales en el parto. Conclusión: el parto se confi gura como elemento material y fenómeno mental de las prácticas sociales. Es necesario romper con Rebirth of childbirth: refl ections on medicalization of the Brazilian obstetric care Renascimento do parto: refl exões sobre a medicalização da atenção obstétrica no Brasil Renacimiento del parto: refl exiones sobre la medicalización de la atención obstétrica en BrasilRebirth of childbirth: reflections on medicalization of the Brazilian obstetric care

Background Regular physical activity is associated with several health benefits, such as lower risk of hypertension, reduced risk of depression, and improved cognition [1-3]. Among the physical activity domains, leisure-time physical activity is a well-established protective factor for several negative health outcomes, including mental disorders [4], different types of cancer [5], mortality due to cardiovascular disease, and all-cause mortality [6]. Beyond its --- Open Access *Correspondence: [email protected] association with health outcomes, LTPA is also associated with a higher quality of life, and wellbeing [7]. However, the promotion of LTPA remains a global challenge. In Brazil, a study carried out with adults living in capital cities reported that the prevalence of LTPA participation was 44% in 2006 and 54% in 2016 [8]. The most widely reported types of LTPA practiced in Brazil were outdoor walking, soccer, and strength training [9]. However, there were important inequalities related to gender, age, and income in the different types of physical activity [9]. Given the inequalities in LTPA, continuous monitoring of these indicators is essential to provide evidence on the trends in inequality and to plan public policies to target risk groups. In Brazil, both the Brazilian Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey and the National Health Survey provide monitoring data on LTPA in the adult population . However, most previous studies carried out in Brazil analyzed only the trend in the level of LTPA [8,[10][11][12], with little available information about trends in types of LTPA [13,14]. Information on the most commonly practiced types of physical activity is strategic because the type of physical activity provides quick, practical, and objective information on preferences and contexts, aspects influenced by culture, the development of personal skills, and inequalities in access to facilities and equipment suitable for practice. Although previous studies investigated the trends in different types of LTPA [15] and social inequalities in the participation in different types of LTPA [9], the trends in inequalities in the participation in different types of LTPA were not explored [15]. Monitoring these trends makes it important to analyze how the participation in LTPA is variating among populational groups constantly unfavored [9], as well as to identify whether changes in the participation in different types of LTPA have been driven by specific subgroups. In addition, given that studies on trends in LTPA level have shown increases, especially among the richest groups [16], increases may occur in specific activities, such as activities traditionally paid. Consequently, understanding these trends can support public policies to reduce inequalities in access to LTPA. Thus, the current study aimed to describe the trends in gender, ethnicity, and education inequalities of types of LTPA practiced by Brazilian adults from 2006 to 2019. --- Methods --- Design and sample This study used data from 2006 to 2019 from the VIGI-TEL survey . The VIGITEL is an annual telephone-based cross-sectional survey with adults living in Brazilian state capitals and the Federal District. To estimate the frequencies of risk factors among the population [95% confidence interval and maximum error of 2%)], the minimum sample size in each city was 2,000 participants. Initially, 5,000 telephone lines were drawn in each city, with stratification by region. After the exclusion of commercial and nonoperational lines, 2,000 lines were randomly selected, and in each household, one adult was randomly selected to respond to the questionnaire. Further information is available elsewhere [17]. --- Leisure-time physical activity LTPA was assessed by the question: "In the last three months, did you practice any type of exercise or sports?". Possible answers were "yes" or "no". Those who answered yes, responded to the following question "What is the main type of physical exercise or sport that you practiced?". Possible answers were categorized into walking , running , strength/gymnastics , sports , and other LTPA . --- Socio-demographic characteristics The socio-demographic characteristics consisted of gender , ethnicity , and education . --- Statistics The descriptive analysis was performed by relative frequencies and their respective 95% confidence intervals . The 95%CI were used to identify the trends in the prevalence of different types of leisure-time physical activity between 2006 and 2019. Absolute differences were used to present the gender and ethnic inequalities, with results reported in percentage points . The Slope Index of Inequality was used to measure the education inequality considering the intermediate group . Equiplots were created using the "equiplot" command . The SII was calculated using the "siilogit" command . All the analyses considered the sampling weights. The analyses were conducted in Stata 15.0 software. --- Results Figure 1 presents the trends in walking, running, strength/gymnastics, sports, other types of LTPA, and no LTPA participation between 2006 and 2019. We noticed increases in participation in walking, running, strength/ gymnastics, and other activities. On the other hand, there was a decrease in sports participation. In addition, we observed a reduction in the frequencies of those who did not participate in LTPA between 2006 [55.9% ] and 2019 [43.0% ]. Figure 2 shows the trends in different types of LTPA and no LTPA participation, between 2006 and 2019, according to gender. In general, we observed an increase in the percentage of women and men who participated in walking [(women, 2006 The Supplementary Tables 1, 2 and 3 present the prevalence and their respective 95% CI of walking, running, strength/gymnastics, sports, other types of LTPA, and no LTPA participation between 2006 and 2019, according to gender, ethnicity, and education level, respectively. --- Discussion We aimed to analyze the trends in the gender, ethnicity, and education inequalities of different types of LTPA among adults living in Brazilian capitals. Despite the general increase in LTPA participation over the years, Fig. 3 Trends in the prevalence of different types of LTPA and no LTPA participation among Brazilian adults living in capital cities, according to ethnicity. Note: Diff is referring to the absolute difference in percentage points. Diff*, black versus white. Diff**, brown versus white. Diff***, Yellow/ Indigenous versus white. LTPA, leisure-time physical activity focusing only on the overall prevalence can hide inequalities among population subgroups. In this sense, our stratified analysis revealed persistent disparities related to gender , ethnicity , and education . Several studies have reported gender inequality in physical activity as a major challenge in physical activity promotion [18,19]. Some factors that help explain these inequalities have been reported in the literature, such as social and cultural norms where involvement in household chores is much higher among women than among men. Even among youth, studies have demonstrated that parental and school support for participation in sports is higher for boys than for girls, demonstrating that actions aiming to tackle gender inequality need to start early [20]. In Brazil, Cruz et al. [8] observed that between 2006 and 2016, men were more active during leisure time than women, with a slight decrease in gender inequality. Fig. 4 Trends in the prevalence of different types of LTPA and no LTPA participation among Brazilian adults living in capital cities, according to education level. Note: SII, Slope Index of Inequality. LTPA, leisure-time physical activity However, we observed different trends depending on the type of LTPA, with an increasing trend of inequality in women being more engaged in walking and strength/ gymnastics, and an increasing trend in men being more engaged in running than women. Despite the changes in the inequalities, we highlight that there was persistent gender inequality, especially in sports participation, which could be the main driver for a higher prevalence of no LTPA participation among women. Although men and women can prefer certain types of physical activities, men reported more LTPA participation than women over all the years analyzed. Thus, our findings suggest that differences in sports participation can be not only a preference, but also a difference in access and support. In this way, promoting the participation of women in sports is a key point to decreasing the gender inequality in LTPA, as well as increasing physical activity levels worldwide [21,22]. We noted trends in the ethnicity inequalities, especially for strength/gymnastics. There were also consistent inequalities over the years, where white people had more access to these activities than their black and brown peers, and the proportion of no LTPA participation was greater among brown than white adults over the years analyzed. The association between ethnicity and LTPA among adults has already been presented in the Brazilian context [23,24], but less is known about the different types of LTPA [9]. Therefore, our findings can be interpreted considering different perspectives. In Brazil, there is great inequality in society concerning ethnicity, including structural racism. For several historical reasons, poverty levels are higher among brown and black people. For example, the percentage of white people with an income below 5.5 dollars a day is 15.4%, while the percentage of black/ brown ethnicities is 32.9% [25]. Higher poverty rates can lead to less access to private structures for physical activity, such as gyms. These findings demonstrate the urgent need for public policies to improve income distribution, giving greater autonomy for individuals to engage in LTPA, as well as enhance other health conditions [26,27]. Our results also indicated that education inequalities increased over the years for strength/gymnastics, with increased participation among those with a higher education level than those with a lower education level. The inequalities also persisted over time for the other types of LTPA, where those with more education presented a higher prevalence of the different LTPA types, except for walking. Likewise, although LTPA is increasing among Brazilian adults, this was especially observed among the higher education group [16]. Thus, our findings expand previous research by showing that the biggest inequalities occurred in strength/gymnastics activities. Some facts can help in explaining these inequalities, for instance, "strength/gymnastics" activities commonly include membership fees, and the fact that individuals with higher education may have higher incomes than those with less education increases the probability of access to this type of LTPA [28]. Other reasons could also partly explain the maintenance of these inequalities over time, such as the unequal distribution of physical activity facilities, which especially affects areas with disadvantaged socioeconomic backgrounds [29]. Our results also revealed that the proportion of participants with no LTPA participation was higher among those with a low education level in 2019 than among those with a higher education level in 2006, reinforcing the urgency to promote physical activity, especially to socially disadvantaged groups. In Brazil, the promotion of physical activity within the Unified Health System is part of the national agenda, with the National Health Promotion Policy [30], Family Health Support Centers, and Health Academy Program [31]. The Health Academy Program is free-of-charge, inclusive, and with easy access to people from different socioeconomic backgrounds, as it is located in the same reference territories as the facilities of the Family Health Strategy teams [32]. In 2017, the Health Academy Program was present in 2,678 of the 5,570 Brazilian municipalities, especially in small municipalities with greater social vulnerability [32]. Despite these issues, universal access to the Health Academy Program is not guaranteed, for reasons related to opening hours , lower participation of men, precariousness in the employment relationship of professionals, and some difficulties in articulating with the network of primary health care services, which can lead to interruptions in the provision of activities [33]. Notwithstanding the importance of these policies for physical activity promotion and reduction of inequalities, since 2016, Brazil has undergone fiscal austerity measures that have deepened the underfunding of the Unified Health System and negatively impacted the functioning of these programs. --- Strengths and limitations Our study has strengths, such as the use of a large sample from 14 different years. On the other hand, some limitations should also be considered, such as physical activity was all self-reported, which could present recall bias. However, currently, there are no viable objective methods available to assess types of physical activity in populational studies. Despite the large population, VIGITEL is representative only of adults living in state capital cities, and consequently, the survey is not representative of non-capital cities and the rural population. The VIGITEL is a telephone-based survey with a sample restricted to people with landline telephones. This limitation in the representativeness could affect the estimates, especially in regions with lower coverage of landline telephones, given that LTPA has been less frequent among those most socially unfavored [34]. Based on our results, strategies to promote physical activity in the population should focus on improving the distribution of physical activity facilities, especially in areas with disadvantaged socioeconomic backgrounds, through the expansion and reinforcement of public policies, such as the Health Academy Program. Furthermore, these strategies could include the improvement of macroeconomic policies to increase the employment rate together with income distribution policies to reduce socioeconomic inequality and the monitoring of barriers to the practice of different types of physical activities among the most disadvantaged groups which, in addition to socioeconomic factors, may include interpersonal factors such as lack of motivation, lack of time, illness and physical limitations [35]. --- Conclusion Even though there was an increase in the participation in different physical activity types, the increase was not equal in all population groups, with women, black and brown people, and subjects with less schooling being the most unfavored groups. In addition, while some inequalities persisted over the years, others increased, such as the ethnicity and education inequalities for strength/gymnastics. Continuous surveillance is essential to explore whether inequalities are reducing, or not and this is even more necessary in the present period, to monitor the inequalities and challenges for physical activity promotion in the "post-COVID era". This specific study did not receive funding. RHOA is supported by the Coordination for the Improvement of Higher Education Personnel with a PhD scholarship . AOW is supported by the São Paulo Research Foundation with a PhD scholarship . DRS is supported by the European Union "NextGenerationEU" for the Recovery, Transformation and Resilience Plan and by the Ministry of Universities, within the framework of the grants "Maria Zambrano" for the requalification of the Spanish university system 2021-2023 convened by the Pablo de Olavide University, Seville. This paper presents independent research. The views expressed in this publication are those of the authors and not necessarily those of the acknowledged institutions. --- Funding --- --- --- Additional file 1: --- --- --- Competing interests Authors declare no competing interests. ---

The current study aimed to describe the trends in gender, ethnicity, and education inequalities of types of leisure-time physical activity (LTPA) practiced by Brazilian adults from 2006 to 2019.We used data from 2006 to 2019 of the Brazilian Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey, which is an annual survey with a representative sample of adults (≥ 18y) living in state capital cities. The types of LTPA considered were walking, running, strength/gymnastics, sports, other LTPA, and no LTPA participation. Gender (women or men), ethnicity (white, black, brown, or yellow/indigenous), and years of formal education were also self-reported. We used relative frequencies and their respective 95% confidence intervals to analyze trends. The absolute and relative differences between the proportions were used to assess the inequalities.We observed increases in inequalities related to gender and education (running and strength/gymnastics), while gender inequalities for sports, other types, and no LTPA participation decreased. There were persistent inequalities related to gender (walking) and education (sports, other types, and no LTPA participation). Considering ethnicity, we noted increases in inequality for strength/gymnastics, where white adults were more active than black and brown adults. In addition, white adults reported more access to LTPA than brown adults over the years analyzed.Women, black and brown people, and subjects with less schooling were the most unfavored groups. While some inequalities persisted over the years, others increased, such as ethnicity and education inequalities for strength/gymnastics.

INTRODUCTION Depression, the most common mental disorder , accounts for 9.7% years lived with disability in the 2010 Global Burden of Disease study. 1 Depression-related disability, compounded by lack of access to care, impacts on social and physical health. Prevalence estimates of depression in India have varied widely depending on the assessment tools used and the community's sociodemographic profile. 2 3 Ganguli 3 reviewed 15 studies of psychiatric morbidity, and found a mean prevalence of 3.4%. Reddy and Chandrasekhar's 4 meta-analysis of 33 572 participants described prevalence at 8.9%, with urban rates nearly double rural rates. Other studies in South Asia have shown even higher rates, for example, 15.1% in urban South India 5 and 45.9% in urban Pakistan. 6 Robust evidence from India and other low and middle income countries links socioeconomic deprivation with increased --- Strengths and limitations of this study ▪ Data derived from this community-based crosssectional randomly selected sample shows that over 6% of adults in Dehradun district, Uttarakhand, are depressed. ▪ Risk of depression is two to three times higher for people who have had very little schooling, who live in poor housing, who have taken a recent loan and who identify as belonging to a Scheduled Caste or Tribe . ▪ There is a large gap in access to effective care: 0% had received talking therapy and only 3.3% of people with depression had been prescribed antidepressants, although the majority had attended a primary care provider in the previous 3 months. ▪ A limitation of this study is that the estimate of prevalence is through a screening tool rather than definitive diagnosis by a psychiatrist. The cross-sectional design cannot indicate causation and the survey covered only one district of Uttarakhand state, which may limit generalisability. risk of depression. [7][8][9] Other groups shown to be at higher risk for depression in India are women, the elderly, urban dwellers and people who are divorced or widowed. 3-5 7 9 India's highly inequitable distribution of mental health resources means at least 90% of people with mental disorders are undiagnosed and untreated. 10 There are also huge disparities in access to mental health services particularly for people in rural areas. 4 Barriers to help-seeking include unavailability of services, poor quality of the majority of existing services, lack of knowledge about mental illness, and fear of stigma and discrimination. 11 12 People with depression in India report distress primarily as unexplained somatic symptoms, and usually seek help from primary care rather than specialist mental healthcare providers. 13 14 Simultaneously, conceptual understandings of depression are not well captured by current disease classification systems 15 and ongoing reflection is needed about when mental distress becomes a disorder. There is an urgent need to understand the burden of disease in areas where prevalence studies have never before been conducted, 16 and to understand the pathways to care currently utilised. 17 Few studies of depression in India have examined the associations between depression and social determinants of health, and almost none have considered the association between depression and caste. 2-5 7 There are very few studies of depression prevalence in the Hindi-speaking belt with existing studies predominantly from Southern and Eastern India. 2-5 9 18 We could find no study on the prevalence or epidemiology of depression in Uttarakhand, a state with a population of 10 million. This study describes the prevalence of depression, sociodemographic associations and the help-seeking behaviours of people with depression. --- METHODS --- Setting This study was conducted in two blocks in Dehradun district, Uttarakhand, as part of the baseline survey for Burans, a community mental health partnership project with the Emmanuel Hospital Association and the Uttarakhand Community Health Global Network . Burans is directed by the first author. Housing is an important indicator of socioeconomic status in this setting. Permanent materials housing refers to housing that is predominantly made with a sealed floor, walls of a solid material and a corrugated iron roof. Temporary materials housing refers to housing with a dirt floor and/or walls and roofing constructed from straw/tarpaulin or plastic sheets. The national District Mental Health Plan had not been implemented in Uttarakhand at the time of this survey. During the survey period, there were two government psychiatrists and no government psychologists, with 10-15 private psychiatrists and psychologists across Uttarakhand. Government primary care services did not generally treat PWMDs, nor did they supply essential medicines such as antidepressants. --- Sample selection We selected 960 people from 30 randomised clusters. Cluster sampling was conducted in three phases: ward or panchayat ; household and participant. We used STATA 19 to calculate a sample size of n=480 3 5 ) and a sampling frame of 235 000 , 30 clusters and 95% CIs. To account for the effects of clustering, we allowed a design effect of 2, giving a final total of 960 persons. Clusters were stratified based on rural:urban ratios in the district's 2011 census, 20 to require 21 urban and 9 rural clusters. These were selected by random number generation from the publicly available list of census panchayats and wards. To select at household level, the surveying team walked to the centre of the community, and spun a pen to ascertain which direction to start. Every 6th house on the right was surveyed, and at each junction, roads/ alleys on the right were followed. If no one was present at a selected household, the team revisited that household later. If no one was present on the second visit, the first house to the right was selected. Only one person from each household was surveyed. Generally, male field staff surveyed male respondents, and female staff surveyed female respondents. Once the requisite 50% of female participants was reached, all survey staff surveyed male respondents. Inclusion criteria were that participants should be occupants of a household, 18 years or older, and able to comprehend and respond to a survey. --- Data collection Project Burans field staff, all from the district of Dehradun , collected data in July and August 2014. All were trained in sampling strategy, use of the survey tool, data recording and management, and ethical research, and were supervised and supported by KM. A comprehensive survey tool was translated to Hindi, back translated to English and piloted extensively by the PRIME team in Madhya Pradesh. 21 The survey was interviewer administered in Hindi. Components reported in this paper are: ▸ Sociodemographic information including indicators of housing quality, indebtedness, caste, marital status, highest education level attained and employment status, adapted from the Indian version of the demographic and health surveys. 22 Proxy measures of socioeconomic status included housing quality, educational status and employment status. We used norms of the Government of India to assess housing quality where permanent material housing referred to classifications of 'Pukka' and 'Semi-kaccha' and temporary material housing referred to the 'Kaccha' classification. 23 ▸ General health help-seeking behaviour and health service utilisation . 23 ▸ Adapted questions from the Client Service Receipt Inventory, 24 used to ask participants about recent inpatient and outpatient services, including type of provider . ▸ Talking therapy or medication prescription received . ▸ Patient Health Questionnaire -a self-report screening tool assessing clinical depression . [25][26][27] This questionnaire comprises nine items, each is scored 0 to 3, which thus yields a severity score from 0 and 27. Response categories, based on frequency of a particular symptom over the last 2 weeks are scored 0, 1, 2 and 3, for 'not at all', 'several days', 'more than half the days', and 'nearly every day', respectively. In our study, a person with a PHQ9 score of 10 or higher was assessed as having at least moderate depression, in line with international norms for PHQ9. 27 ▸ Mental health service seeking behaviour among those screening positive for depression using the same codes as for general health seeking behaviour. At census enumeration and on birth registration, Indians of Jain, Sikh and Hindu religion must identify themselves as General Caste, Other Backward Classes or a member of a Scheduled Tribe/Caste , based on the identity of their parents. 28 In the Dehradun area, the vast majority of Muslims are included under the OBC category. Christians and Buddhists are classified into the General Caste category. --- Analysis Survey data were analysed using STATA V.13.1. 19 Open text was translated into English, grouped thematically and coded. Univariable logistic regression analysis was performed using all relevant socioeconomic variables and significant variables were considered in the multivariable logistic regression analysis. The dependent variable was dichotomised: no depression=0, depression=1. The original interpretation defined a total score of 5-9 as mild depression, and above 9 as moderate-to-severe depression. In this study, we designated all respondents with a score of greater than 9 as being 'depressed'. χ 2 Test was used in analysis of tables 1 and 2. A p value <0.05 was considered statistically significant. All participants gave written consent to participate in the study, and respondents who screened positively for depression were given information on depression, and advised on health services and other sources of help. --- RESULTS Within two contact attempts, 958 of 960 selected households were successfully surveyed and the remaining two were surveyed on the third visit. Survey participants' demographic characteristics are summarised in table 3. Nearly one-quarter were lowest caste or had tribal status . Thirty-five per cent had six or fewer years of schooling. The sampled survey population had a mean age of 39.4 years and a median age of 37.5 years. The mean period of education completed was 8.0 years and the median was 9 years. The sample differs significantly from the wider Uttarakhand population 20 by greater representation of middle-aged people classified as SC/ST and unschooled people. Table 4 summarises the prevalence of depression, sociodemographic characteristics and their association with the PHQ9 depression score with crude and adjusted ORs. Depression prevalence was 6%. The significant association with increased risk of depression in women disappeared when other confounding factors such as educational status and economic deprivation were accounted for. People in their middle years had a slightly higher risk of depression than those under 30 years and over 50 years of age. People who lived in a house made of temporary materials were almost twice as likely to be classified as depressed, and those who had taken a loan recently were three times more likely. Those classified as SC or ST had three times the odds of being classified as depressed. A dose-response relationship was seen in educational status, with risk of depression increasing with decreasing years of completed schooling. Table 1 shows the help-seeking behaviours of those screened as depressed or who selfreported a >2 week episode of depression in the last 12 months. People with depression were five times more likely to have visited outpatient or inpatient providers than people without depression. Separate analysis showed that all women, with and without depression, were significantly more likely than men to have visited a health provider in the prior 3 months. Table 2 shows the type of health provider visited by the 183 people who made an outpatient visit in the previous 3 month. Depressed people, compared to nondepressed, consult health providers significantly more, and are far more likely to visit general health providers than to visit mental health services. Only two people had visited a mental health service provider in the previous 3 months. No one with depression had received talking therapy. Two people with depression at the time of the survey had been prescribed antidepressants through private practitioners, while one respondent who screened negatively for depression had been prescribed antidepressants. --- DISCUSSION This study shows a 6% prevalence of depression using a depression screening tool in a randomly sampled population in Dehradun district, Uttarakhand. Some studies suggest prevalence in India may be higher. 4 6 29 In this study, no one had received talking therapy, indicating a treatment gap of 100% for the recommended first-line treatment of mild or moderate depression. 30 Antidepressants are the recommended second-line treatment for depression, 30 and although we cannot ascertain how many of the 96.3% people would have benefitted from these medicines, it is likely this also represents a large treatment gap. Extrapolating these findings to Uttarakhand's adult population of 6.6 million, 20 we estimate 400 000 people may have depression, of whom just 4000 may have access to antidepressants and almost no one is likely to have access to talking therapy-a huge mismatch between disease burden and health service provision. This study shows much greater risk of depression for three groups-the poorest ; those who self-identify as OBC, SC or ST; and the unschooled/illiterate. Each of these associations has an adjusted OR for depression of at least twice that of their reference group. A systematic literature review in LMIC shows depression to be strongly associated with socioeconomic deprivation, 8 supporting the WHO Commission on the Social Determinants of health concept of mediating pathways that link poverty with lack of access to political recognition and economic power. 31 Other Indian studies also suggest socioeconomic factors as the key determinants of depression. 4 5 7 Similar to a 'canary in a coal mine', depression may be conceptualised as an indicator of social inequity and vulnerability. Although mental health has been linked with socioeconomic disadvantage and social exclusion, caste, a key indicator of social identity in India, has not been well investigated as a risk factor. One Indian study of the prevalence of CMDs among rural women found no association with caste. 7 A further study in rural Nepal found that caste-based disparities in mental health are mediated by poverty, lack of social support and stressful life events. 32 However, Sen's 33 capabilities approach emphasises rights and command over goods, recognises the relational roots of deprivation, and underscores the importance of agency and participation for genuine social inclusion. This view is supported by others describing psychosocial and biological pathways between social exclusion and health. 34 35 It seems likely, therefore, that social exclusion, marked by caste, increases the risk of depression. For decades, Indian national policy has sought to legislatively benefit SC and ST, for example, the Reservation in Admission Act 2006 36 and the Protection of Civil Rights Act 1955. 37 Despite such measures, and even after controlling for socioeconomic status , members of SC and ST groups in this study had more than twice the risk for depression compared to the General Caste. It is likely that persisting social structures of exclusion and discrimination are more penetrating than legislation, and that they continue to create relative deprivation, reduce agency and exclude people. Associations between poverty and CMDs in LMIC countries and in India are well described. 13 This study found that depression prevalence among people who had taken a recent loan was thrice that of those who had not. Two other studies from India show indebtedness as a risk factor for primary care attenders diagnosed with a CMD. 13 38 Links between personal debt and mental health are well described, 13 39 40 although there have been no prospective longitudinal studies to show the direction of association. Possible mediating pathways between depression and indebtedness include shame, stress of financial insecurity 39 and less capacity to earn income due to depression. Another strong risk factor for depression in this study is educational status. People who had not completed primary schooling had almost four times greater risk after controlling for caste, housing, indebtedness and employment status. Our results show a striking doseresponse relationship: increasing years of education provide increasing protection. A meta-analysis examining the associations between socioeconomic inequality and depression also reported this finding. 41 Education status has been described in India and other LMICs as predictive of mental health outcomes. [41][42][43] Social consequences of low levels of education are multiple and move beyond schooling as a marker of deprivation, including reduced opportunity to access resources, and to develop protective social and cognitive skills, and increased risk for mental distress. Reverse causality is unlikely to be a factor, as primary education occurs at an age when CMDs are uncommon. Although people with depression were seeking care, they were not getting the help they needed. This study shows that most people with depression had attended primary healthcare providers in the previous 3 months, in the Government as well as in the private sectors. The somatisation of depression among people with depression in Asian cultures, particularly women, is well described. 44 Many health providers are unable to recognise somatisation, leading to excessive, costly and often inappropriate investigation and treatment. Also noteworthy is that only eight people in this sample reported consultations with traditional healers. Others have described up to two-thirds of people with severe mental disorders in India seeking help from traditional healers during their illness. 17 The strong association between somatoform disorders and CMDs highlights the need for primary care providers to be equipped with knowledge and skills to recognise and manage the diverse presentations of CMDs. 14 44 This study shows depression as a community outcome of macroeconomic and political decisions that can lead to mental distress and suffering for communities as well as for individuals. There are several important implications for policy and practice. Foremost, since social determinants of health almost certainly contribute to depression, macropolicies that address determinants such as poor housing, caste, indebtedness and low education, will also reduce depression disease burden. Policies to improve mental health must seek to reduce poverty and social exclusion 45 and actively include communities. Second, action is urgently required to increase provision of mental health services and medicines, as strongly advocated by the Lancet mental health group and series. 29 45 However, perhaps more importantly, primary care doctors in India, being the healthcare providers most commonly consulted by people with depression, 9 14 need the knowledge, skills and perception to recognise the diverse presentations of CMDs such as depression and anxiety, and to treat them appropriately with both talking and pharmaceutical therapies. --- Methodological considerations A major strength of this study is that its data are from a randomly selected population covering rural, semiurban and urban populations typical for a district in North India, in 2014. Multivariable analysis ensured that potentially confounding factors were considered. However, there are some methodological limitations: self-reported measures may risk recall bias and cultural factors. PHQ9 is a screening-not diagnostic-tool constructed using a definition of depression ; it has been critiqued as being over simplistic and risks labelling components of normal human experience as a disorder. 15 This cross-sectional study cannot attribute causality to apparent risk factors. The survey tool excluded three key risk factors-stressful life events, chronic illness and disability. The lower than expected prevalence of depression may be related to the emphasis in the PHQ9 on cognitive manifestations of depression possibly missing the somatic features common in Asian cultures. 44 CONCLUSION Depression in Dehradun district of Uttarakhand, with a prevalence of at least 6%, is two or three times more common among people who are economically deprived, those who are part of the most excluded caste group or those who have had little education. Almost no one with depression accesses effective primary or secondary mental healthcare. Social policy and health service responses must urgently address this preventable and treatable disease burden and treatment gap. CMDs are indeed common, and disproportionately affect the most vulnerable.

Objectives: This study sought to use a population- based cross-sectional survey to describe depression prevalence, healthcare seeking and associations with socioeconomic determinants in a district in North India.

Introduction Stigma of mental illness constitutes a major problem worldwide [ 1 ]. It not only affects people living with a mental illness [ 2 ], but also their families [ 3 ]. Referred to as "courtesy stigma" [ 4 ], "associative stigma" [ 5 ], "stigma by association" [ 6 ] or "family stigma" [ 7 ], it is widespread, and occurs across cultures, regardless of nationality and socioeconomic status [ 8 -12 ]. It exists in different domains of life [ 12 ] and is associated with both subjective and objective burden of family members [ 6 , 7 , 9 , 13 -15 ]. A variety of campaigns have been undertaken to tackle stigma [ 1 ], and some have been shown to be successful [ 16 , 17 ]; however, they are generally broad, nonspecific, and their effect size is moderate [ 18 , 19 ]. Interventions seeking to reduce stigma in the family context are scarce and rarely take into account the views of service users [ 18 ]. Further research is needed to better understand how stigma is experienced in the family context, and how these experiences vary in different cultural contexts, i.e. "what matters most" in different settings [ 20 ]. Information of this type is essential to inform the development of interventions that take into consideration the effects of stigma and its crosscultural variability [ 18 ]. There is very little evidence available from Eastern Europe [ 21 ] and to the best of our knowledge, this is the first paper presenting firsthand experience of families of people receiving mental health care in Belarus. Information of this type is particularly important in countries of Eastern Europe as there is insufficient development of communitybased treatment [ 22 , 23 ] and most of the care for mentally ill people, particularly those who are severely and chronically ill depends on the FMs. http://eproofing.springer.com/journals/printpage.php?token=zfEkPK0hxFSkaPTm8Ev4zzxasfo0Hu5nzIlmdCOKe3VhJ_U5M_rA 4/25 We undertook a qualitative study of the firsthand experience of FMs with three main objectives: to investigate experiences of stigmarelated challenges of the FMs of people living with schizophrenia in Belarus, both in the private and public domain of life; to identify strategies that FMs use to face the stigmarelated challenges in Belarus; to identify relevant and acceptable targets for interventions to help overcome stigmarelated challenges for families within the Belarusian context. There is a lack of widely accepted theories on stigma within the family. With an awareness of the existing conceptualizations of stigma [ 20 , 24 -28 ], we upheld a broad perspective and took an inductive approach to the experience of stigma rather than the process of stigma per se. Therefore, the analysis was focused on "the direct experience of stigma related challenges by FMs of PLS", and specifically any examples of devaluation experienced by FMs either in the private or public domain because of the presence of schizophrenia in the family. By "private domain of life", we meant personal relationships, interests, and activities as distinct from public or professional life [ 29 ] and focused on discrimination within a family, in relationships with neighbors, friends and colleagues. In contrast, by "public domain of life" we meant experience of contacting social institutions and focused on stigma and discrimination in these contexts . We here present results related to the experience of stigma and discrimination in the private domain of life of FMs of PLS. The materials of the study related to the stigma and discrimination in the public domain are available on request from the authors and will be published in a separate paper. --- Methods The research participants were recruited via purposive sampling in both Minsk and Grodno, so as to obtain data from the capital and a regional city. To achieve maximum variation, we recruited cases according to the following core attributes for the sample: FM and PLS sex and age , duration of disease , degree of kindred (first degree relative http://eproofing.springer.com/journals/printpage.php?token=zfEkPK0hxFSkaPTm8Ev4zzxasfo0Hu5nzIlmdCOKe3VhJ_U5M_rA 5/25 , second degree relative, distant relative or other). Before approaching FMs, we contacted the patients, described the study and asked them for permission to approach the nominated FM. After obtaining the permission, researchers contacted the selected FMs, described the study, asked them to sign informed consent and conducted semistructured indepth interviews [ 30 ]. A topic guide was developed based on a literature review [ 4 , 10 , 15 ], consultations with service users and mental health professionals, which was piloted during initial interviews . Interviews lasted approximately 1.5 h, were conducted in Russian, recorded digitally, and transcribed verbatim. Two bilingual members of the research group proceeded with the thematic analysis [ 31 ] in Russian. Coding of the interviews was done by hand and both analysts independently processed each interview. Analysts initially familiarized themselves with the data by listening to the recordings and transcribing them. Words, phrases and larger sections of text were highlighted and coded to identify relevant themes. Discrepancies in the coding were discussed and resolved. The final list of themes was discussed with other members of the research team and adjusted until final agreement was reached . The final results and supporting quotations were translated into English and doublechecked by bilingual and native Englishspeaking authors. The study was approved by the Ethical Committee of Belarusian Psychiatric Association . --- Results --- --- Stigma experience Following thematic analysis of the interviews, we grouped the experiences of FMs into three main themes: challenges in the private domain; subjective burden and feelings associated with experiences of stigma; challenges in the public domain. As previously mentioned, results related to stigma in the public domain are covered in a separate paper, and are available from the authors. --- Challenges in the private domain Experience of stigmatization in the private domain is covered within two subtopics: attitudes within close environment and life within the family. In relation to the attitudes within close environment nearly half of respondents expressed suspicions that derogatory attitudes are hidden and/or apprehensions that there may be "bad" or "dangerous" consequences to the relatives, partners), half of the respondents described difficulties, with a tendency of families to come apart following the diagnosis of mental disorder. The breaking up of the family happened in different ways: divorces from the PLS, with the PLS returning to the parental family ; former spouses initiating the process of governmental removal of children from the PLS' parental custody ; general reduction of contacts from the rest of the family with primary carer and a PLS . As a consequence of such family break up, more than a third of the FMs providing primary caregiving were the only people remaining in the life of PLS, and were bound to them without the possibility of temporal separation. "Her husband returned her to me and said: come and take back this schizophrenic." . "Children were taken away from her." . "Everyone has abandoned him." . "X. once went to my brother, but they refused even to let him come into the house. X was sitting on the bench all the time. He called me and said: "Come here and take him back!" and didn't even allow him to enter, do you understand? …. Earlier we communicated somehow. But later when he married his wife forbade it because "Children will be afraid of X". That is it. Do you know how painful it is for me to bear this." . "My sister asks: "Why don't you visit me?" This summer I replied: "Ok, let me come with X!" She: "No, I do not need this tagalong". I.e. no one needs him. So, he will stay, and I even do not have anyone to be his guardian … So, everyone has abandoned him." . --- Subjective burden Respondents expressed a number of negative feelings associated with being part of a family with a PLS. Shame and/or guilt were the feelings most frequently mentioned as burdensome in one form or another: guilt for the lack of awareness of the need for treatment, denial of the need for treatment during the first years of the disorder; "sins", "bad actions" that were perceived as a possible explanation of the onset of the disorder ; vague reasoning ; shame caused by the patient's bizarre behavior in public . FMs expressed fear, anxiety and hopelessness related to the presence of diagnosis within a family, which were mainly connected to uncertainty about the future. Lack of support from the rest of the family and within the health care system worsened the situation. More than third of primary carers expressed tiredness, loneliness and regret as a consequences of the family dissolution following the diagnosis of schizophrenia. "What will happen after I am not able to care for X?" . "Who will take care of me when I am old?" . "I don't see how it may be resolved" . Amongst other emotions, regret, sorrow and mourning, feelings of loss, frustrated hopes were often mentioned , as well as overload and depression . In most cases , the first episode of psychosis, the first hospitalization and especially the first exposure to the diagnosis of "schizophrenia" were mentioned as the most stressful and difficult period for the whole family. Respondents remembered feelings of despair, hopelessness, shame, and fear. home, I howled at nights for many years." . "I was very upset, we were crying for weeks-me and my wife. We didn't know what to do. We felt bad… it was very hard in the beginning… there were thoughts that a person's life is crippled." . Strategies that FMs use to overcome stigma in the private domain Strategies adopted by respondents to cope with stigma and discrimination in the private domain included: concealment, avoidance of the rest of the family and taking full responsibility and sacrificing one's personal life. The whole set of strategies to cope with stigma and discrimination in both the private and public domain of life is presented in the Appendix 2 . --- Concealment Suspicions and fear of experiencing derogatory attitudes towards the family, or lived experience of it, due to the presence of a PLS within the family, lead to the tendency to "live behind closed doors", hide, and to pretend a "normality in the eyes of others". More than a half of respondents reduced contacts with the external world, and tried to avoid social activities. If these were unavoidable, they would prepare the PLS so that they looked and behaved "as normal" . Even if the current situation resulted in a significant burden, the relative were not ready to implement any alleviating actions or share their difficulties with others. --- Avoidance of the rest of the family More than twothird of FMs who were not primary caregivers expressed a tendency to stay away from PLSs or even leave the family because of "lack of practical knowledge", general "tiredness" and "fear of consequences" for their personal life and career if the diagnosis within their family was disclosed. At the same time, they mentioned feelings of shame and guilt because of this. Taking full responsibility and sacrificing one's personal life Insufficient support in mental health care and from the rest of the family, and living life "behind closed doors" whilst avoiding contact with the external world led to FMs bearing substantial responsibility for the actions of PLS, and totally controlling their decisionmaking. The majority of primary caregivers mentioned this. At the same time, FMs were usually aware of the necessity to reduce control over the PLS's actions, so as to increase their autonomy. "We all must somehow to let children go. However, he is "like this" . But even if he is "like this", he also must be somehow, slightly, although maybe not totally, released … but I don't know how." . Respondents expressed perplexity in such ambivalence and lack of knowledge on how to manage the situation. The intense devotion to the life of the PLS led to FMs sacrificing their own personal lives, with an inability in some cases to even express their own needs . --- Requests for interventions to decrease burden of stigma and discrimination in private life of FMs Interventions mentioned by respondents as possibly helpful to decrease stigmarelated challenges in the private domain included provision of better access to appropriate information and assistance in the life of PLS. --- Information and education One of the main needs of FMs mentioned by 40 % of respondents, was that of access to correct information that is delivered sensitively. Part of the request was related to advice on ways of treating and managing relapses, and of solving difficulties in relationship within a family, e.g. how to communicate with other FMs and PLS, how to discuss challenging situations within the family. Although there are taboo or difficult issues that need to be discussed, but relatives either do not know how to raise these issues, or are afraid of doing so . "What I would like to change in the medical services is to increase the quantity of available information… about new approaches. And it should not be my responsibility to elicit this information, but someone else who will give it to me… but there is nobody…" . "I would like to be guided when I address the doctor. How should I behave in these situations? Should I call the police or should I not? Should I wait for X. or talk to her somehow specifically? How to behave, how to act? How to persuade her? I.e. I need some kind of recommendations on how to behave with her." . --- Assistance in the life of PLS Nearly half of respondents also expressed a wish to help the patient with having more communication with peers, assist them in socializing and in living a more independent life. "I would be happy if there were at least somewhere where he could spend time with peers drawing or doing some job", "I only want him to be able to communicate more with his peers." . --- Discussion The results of the study shows the presence of stigma experience in the private life domain of the family members of people living with schizophrenia with a specificity of the stigma experience in primary and secondary social groups. Life within primary social group was described as changed after onset of mental disorder mainly because of dissolution of families . On the other hand, within secondary social group stigma was perceived as problematic predominantly due to suspicions of hidden discrimination and apprehension of bad consequences in the case of the diagnosis http://eproofing.springer.com/journals/printpage.php?token=zfEkPK0hxFSkaPTm8Ev4zzxasfo0Hu5nzIlmdCOKe3VhJ_U5M_rA 14/25 disclosure, although there were relatively few examples of perceived stigma, and direct discrimination. Whereas experience of perceived stigma within a primary social group was salient in the study, this was not the case in the secondary social group. There was a contradiction between anticipated and perceived stigma while contacting outsiders. On the one hand, respondents presented feelings of fear, suspicions and apprehension of possible hidden discrimination and its consequences. On the other hand, the majority of these respondents could hardly remember real examples of discrimination and were satisfied with the relationships with friends, neighbours, colleagues. This contradiction was previously discussed in relation to associative stigma by Catthoor et al., who noticed a marked difference between the presentation of the perceived stigma and feelings associated with it. In particular, respondents claimed there were no problems in contacting outsiders although they tended to conceal and keep the disorder secret [ 11 ]. This phenomenon of mismatch between experienced and anticipated discrimination was described even more thoroughly in research on stigma towards people with mental disorders. It has been found that anticipated discrimination was reported more frequently then experienced acts of discrimination and not necessarily associated with it [ 2 , 32 ]. The described mismatch was however not found within the primary social group in the current study, where clear examples of family dissolution with consecutive challenges and subjective burden of caregivers were presented. This is in line with other research showing relationships problems within the family [ 33 , 34 ] and deterioration of relationships with extended family because of a relative with a mental illness [ 6 , 9 , 13 , 14 ]. According to the theory of Yang et al. [ 20 ] [ 35 ], where family was ranged as the most important value . The literature on coping strategies for carers of people with psychosis [ 36 -40 ] has highlighted the importance of understanding both the severity and scope of the problems, and how carers appraise the situation and cope with it [ 37 , 38 , 41 ]. Adequate coping strategies promote good living environments and reduce the level of expressed emotion, which have been shown to play a substantial role in both the burden of carers and patients outcomes [ 42 -44 ]. Life behind closed doors, avoidance of distant relatives, taking full responsibility for the life of patients and sacrificing one's personal life were the strategies mentioned by the study's respondents in relation to stigma in the private domain. The overall solution to cope with stigmarelated challenges in the family was "living a hidden life" or "behind closed doors". This strategy resulted in social exclusion of the direct caregiver, and burdensome feelings that included guilt, tiredness and loneliness, together with fear and anxiety due to uncertainty in the future and feelings of loss and frustration because of hopes for a better life held in past. In summary, according to the data of the current study, stigma experience in the private life of family members of people living with schizophrenia includes anticipated stigma within the secondary social group; dissolution and lack of support within families; strategies to conceal disorder, living a hidden life behind closed doors and taking full responsibility for the life of the patient; being exposed to resulting subjective burden. In a situation of this sort, access to appropriate support and assistance provided by mental health care could improve the quality of life of family members. However, mental health care in Belarus is hardly able to provide such support, as it has just recently started a deinstitutionalisation process of its services [ 23 , 45 ] and is still based in centralised psychiatric hospitals . Institutionalised mental health services are known as associated with structural stigma, bad living conditions [ 46 , 47 ], human rights abuses and negative outcomes from longterm treatment [ 48 ]. Lack of appropriate support from mental health service, absence of peer support groups, patients and family organizations http://eproofing.springer.com/journals/printpage.php?token=zfEkPK0hxFSkaPTm8Ev4zzxasfo0Hu5nzIlmdCOKe3VhJ_U5M_rA 16/25 in Belarus make the situation even worse. Breaking the vicious circle of disempowered families and nonresponsive mental health service is an important direction for addressing the burden of stigma within families of people with schizophrenia in Belarus, what should be a priority for reforms of mental health care. Number of approaches have been offered to tackle stigma and discrimination [ 49 , 50 ]. We recommend the implementation of several such strategies in Belarus. For example important steps to be taken include: empowerment of family members as well as people with schizophrenia themselves; their inclusion in decision and policy making; reforming mental health service with increased access to care within communities; development of family support services; facilitating appearance of service users and family organisations; assistance in communication, resocialisation and independent living of people diagnosed with schizophrenia [ 49 ]. --- Strengths and limitations There are a number of limitations to our study. Firstly, it is difficult to generalize the results because participants were recruited through mental health services, potentially resulting in the overrepresentation of the views of people who are in touch with services. Secondly, interviews were conducted and analyzed by researchers who are both clinical psychiatrists from Belarus. This may have led participants to focus more on their experiences from the perspective of mental health services. Third, difficulties with conceptualisation of the phenomenon studied must be taken into account. It was at times not clear where to draw a line when trying to separate direct experience of discrimination from indirect. The difficulty in separating direct and indirect experience of discrimination was also an issue in other studies on courtesy stigma [ 4 , 15 ], where "it appears to be difficult for relatives to draw the line between negative reactions targeted at themselves and those targeted at mentally ill. Relatives feel, thus, stigmatized in a double sense" [ 4 ]. In addition, stigma is a complex phenomenon multiply interwoven with other life experiences such as burden, illness manifestation, relationship within a family, social interactions, contacts with health service and other public institution [ 6 , 51 ]. Therefore, it was not always possible to differentiate whether the topic discussed was related to stigma, to its consequences or to some other concept . However, the study has many strengths, including: the use of an inductive approach in the analysis of participants' accounts of their experiences; involvement of mental health professionals and service users while planning and conducting the study. --- Practical implications Based on the results of the study a set of recommendations on reduction of stigmarelated burden in Belarus might be produced. To tackle the stigma and discrimination in families of people living with schizophrenia it is important to promote empowerment of families, their inclusion into the decision and policymaking processes. Other important components would include providing better access to correct information, support of people living with schizophrenia in their communication skills, resocialisation and independent living. ---

Family stigma constitutes a major problem in schizophrenia worldwide. Data on firsthand experience of stigma in families is necessary for planning and implementing interventions to reduce its burden. The aim of the study was to investigate the experience of stigma among relatives of persons with schizophrenia in Belarus.Qualitative research methods, such as the thematic analysis of indepth semistructured interviews with 20 relatives of people diagnosed with schizophrenia, were used. Experience of discrimination, strategies used to cope with it, and requests for interventions were investigated.The most salient themes in experience of stigma in the private domain of life elicited in the narratives included anticipated stigma and dissolution of families. The experience of stigma was associated with burdensome feelings of guilt, tiredness and loneliness, together with fear and anxiety due to uncertainty in the future and sorrow because of frustrated hopes in past. Analysis of the strategies used to overcome the difficulties revealed concealment and "life behind closed doors", avoidance of the rest of the family, taking full responsibility and sacrificing one's personal life.To reduce the burden of stigma in the private life of the family members of people living with schizophrenia in Belarus, important steps should be taken to promote the empowerment of families including: reforming mental health services; provision of better access to information; family 2/10/2016 e.Proofing http://eproofing.springer.com/journals/printpage.php?token=zfEkPK0hxFSkaPTm8Ev4zzxasfo0Hu5nzIlmdCOKe3VhJ_U5M_rA 3/25 support services, community care; development of family organisations; assistance in communication, resocialisation and independent living for people diagnosed with schizophrenia.

Introduction The COVID-19 pandemic has had a profound impact on individuals, communities, and health systems worldwide. However, certain populations have been disproportionately affected by the pandemic, including People living with HIV . This is due to several factors, including the fact that many people living with HIV face additional challenges, such as stigma, discrimination, and limited access to healthcare, which can exacerbate the impact of the pandemic on their health and well-being. PLWHV are unique due to their dysregulated immune system from their history of chronic HIV infection and their use of antiretroviral therapy, some of which have been used experimentally to treat COVID-19 infection . Apart from immunosuppressed individuals, people living with HIV are at risk of more severe COVID-19 infection as a result of overlapping demographic and medical characteristics that are known risk factors for severe COVID-19 diseases . In a systematic review conducted by Ssentongo et al, , it was found that people living with HIV have a higher risk of SARS-CoV-2 infection and mortality risk from COVID-19 than people without HIV. The prevalence of HIV in COVID-19 patients and associated mortality vary across the world . Many researchers have highlighted the urgent need for PLWHV to be vaccinated against COVID-19 . A study in South Africa reported that PLWHV especially those not on antiretroviral therapy were at risk of severe infection from COVID-19 and vaccination should be a priority for them . Immunity is already compromised as a result of HIV infection, now having a dual combination of viral infection with COVID-19 may lead to a more severe medical burden on the affected individual. Since there is no specific treatment for COVID-19, vaccination is still one of the most effective means of preventing the disease . Across the world, there have been so many rumours and misinformation circulating the globe concerning COVID-19 vaccines. It has been reported that people who were fully vaccinated died of COVID-19-associated symptoms, which has deepened public uncertainty about the safety and effectiveness of the vaccines. About 37.7 million people were reported to be living with HIV globally . There are currently 1.8 million PLWHV in Nigeria, 1.5 million of whom are on ART . Since COVID-19 vaccination began, only about 3% of the eligible population has been fully vaccinated . COVID-19 vaccination among people living with HIV has been reported to be low . In a study carried out among PLWHV , it was reported that COVID-19 vaccination uptake was low and stated that PLWHV will probably not get vaccinated as a result of vaccine safety and side effects. A study carried out on the acceptance of COVID-19 vaccination in China also reported a relatively low COVID-19 vaccine acceptance rate among PLWHV compared to the general population . In another study conducted among PLWHV in Nigeria, COVID-19 vaccine acceptance was low and was associated with respondents' faith, risk perception, perception of the protective effects of antiretroviral treatment, concerns about COVID-19-HIV co-infection, and infertility-related misconceptions . There is little evidence as regards the perception of PLWHV in Nigeria towards COVID-19 vaccine which will be an important determinant in vaccine acceptance and uptake. Hence, this study aims at determining the perception of COVID-19 vaccines among People living with HIV in Ogun state, Nigeria. --- Methods --- Design The study is a quantitative design, adopting a descriptive, cross-sectional approach to determine the perception of COVID-19 vaccines among people living with HIV in Ogun state, Nigeria. --- Setting and Participants The study was conducted among people living with HIV who attended HIV support groups in selected Local Government Areas in Ogun State. There are between three and four active support groups per LGA, each with an average population of about 330 regular members and an estimated total study population of 660 regular members across the two selected LGAs in Ogun State. The target population is the people living with HIV between the ages of 18-64 years old and are registered members of HIV support groups in Ogun State, Nigeria --- Sample size determination The sample size was determined using Charan's formula , a 95% confidence interval, 5% margin of error and estimated proportion of 82.94% representing the proportion of PLWHV with a positive attitude toward COVID-19 vaccine in a similar study . After adjusting the minimum sample size for a 10% non-response rate, a sample size of 243 was derived. Samples were selected through a three-staged probability sampling scheme. In the first stage, two LGAs were selected purposively, and two support group each was selected by simple random sampling out of the three HIV support groups in each LGA. In the second stage, a list of all duly registered members of the selected support groups was obtained and a computer-generated randomization scheme was used to select study participants. --- Data collection The study data were collected using an intervieweradministered structured questionnaire with closedended questions. The study adapted items from previous research and literature review to assess the perception of COVID-19 vaccines among People living with HIV . Section A consists of questions that assessed participant characteristics, including sociodemographics. Section B assessed the COVID-19 vaccines related concerns and Section C assessed the perception of PLWHV towards COVID-19 vaccines. --- Recruitment and training of research assistant Five research assistants who were graduates of health and related disciplines and spoke both English and Yoruba languages fluently were recruited for data collection. The researcher conducted two days of training each lasting five hours on the objectives and processes of the research for the research assistants. The training also included ethical conduct of research and all study staff passed the Nigerian National Code for Health Research Ethics online course. --- Validity and Reliability The questionnaire was first assessed by two epidemiologists who determined that the scales had both face and content validity. The questionnaire was then pre-tested among people living with HIV in Oyo State, Nigeria based on the assumption that PLWHV in southwest Nigeria have similar characteristics. The goal of pretesting was to assess the acceptability and ease of answering the questions, as well as their tendency to elicit appropriate answers. --- Data analysis Data were analyzed using SPSS Version 22. Means and standard deviations were used to summarize numeric data. Frequencies and percentages were obtained for categorical variables. The proportions of all measured variables were computed and presented with relevant tables and charts. --- Results --- Participants' sociodemographic characteristics and clinical characteristics. A total of 236 properly filled responses were received, giving a response rate of 97.1%. Table 1 shows the sociodemographic characteristics of the study participants. The majority of the participants are females, with an average age of , 40.7% are married, 61.4% are Christians and a majority of them are from the Yoruba ethnic group. More than half, of the participants had secondary education. The majority of the study participants had comorbid medical conditions. The majority of the respondents believe that getting the COVID-19 vaccine will protect themselves, their families, or their patients and that it will help prevent the transmission of the disease . There is also a large percentage of respondents who believe that the vaccine is effective and safe and that it confers long-term immunity . . We assessed the perception of the COVID-19 vaccine alongside the vaccine-related concerns among PLWHV in Ogun state, Nigeria. We found that the majority of the study participants have a good perception towards the vaccine. Nearly two-thirds of the participants in the study also identified vaccine-related concerns which may have affected the uptake of the vaccine, this may indicate that there is poor knowledge of the dangers associated with COVID-19 infection among PLWHV. Moreover, the vaccine-related concerns reported mostly by the respondents were that the COVID-19 vaccine has serious side effects, and can aggravate health conditions. Less than half of the respondents reported that the virus can be gotten from the vaccine, while a small proportion also prefer to acquire COVID-19 immunity by getting infected with the disease rather than take the vaccine. Perception of COVID-19 vaccine in our study was in contrast with the study carried out among the general population in Nigeria where a poor perception of COVID-19 vaccine was reported among the participants . The good perception in our study might be due to increased health education and awareness at HIV clinics about the vaccine's benefits and effectiveness. The reported vaccine-related concerns in our study was similar to the study carried out in China where long time side effect of the COVID-19 vaccine was also reported as a major concern . The study carried out among the general public in Nigeria also reported vaccine side effects as a major concern for vaccine acceptance . The fact that this concern has been reported across several studies indicates a lack of public awareness about the proven safety and efficacy profile of the COVID-19 vaccine not only among PLWHV but across the general population. The result of these findings indicates that a good perception alone is not enough predictor for vaccine acceptance or uptake if vaccine-related concerns are not addressed among the target group. It also suggests that people are more likely to vaccinate if they are presented with information from trusted sources that will eradicate their fears and doubts when rolling out new vaccines. Being responsive to the concerns and information needs of vulnerable groups holds the key to the successful roll-out of vaccines , interventions should focus on the provision of essential information about the COVID-19 vaccine. --- Study limitations There were a few limitations in the study. The study design was cross-sectional and the findings could differ over time. Since all COVID-19 preventive measures have been eased out and daily reports of infected people with COVID-19 infection have reduced, this may have changed the perception of the target population compared to when the pandemic was still very active. Since our study was among PLWHV, the findings cannot be generalized to the general population. --- Conclusion One of the most important predictors of vaccine acceptance among PLWHV is the perception of the safety and effectiveness of the available COVID-19 vaccines. The majority of our participants have a good perception towards the COVID-19 vaccine, but not without vaccine-related concerns that may affect the uptake of the vaccine. COVID-19 vaccination of PLWHV is important because of their already immunocompromised state, yet vaccine coverage among them was found to be below recommended targets. Since perception and misconceptions are known to affect vaccine coverage , it is, therefore, recommended that vaccine education and more awareness to clarify misconceptions and misinformation as regards vaccine development be addressed to improve the overall COVID-19 vaccine uptake among PLWHV. research assistants for their efforts to make this research a success. --- List of Abbreviations The research assistants stressed the voluntariness of participation and withdrawal at any point during the study without negative consequences. Data confidentiality was assured and ensured. All study data were de-identified, while the names and addresses of the participants were not required. Instead, everyone was allocated unique identifiers before the commencement of the study. All the respondents gave written informed consent. All relevant ethical principles were also adhered to. --- --- --- Competing interests The authors declare that there are no conflicts of interest. ---

Since there is no specific treatment for COVID-19 infection, vaccination is still one of the most effective means of reducing the severity of the disease. Despite the rollout of COVID-19 vaccines, evidence has reported low vaccine acceptance, especially among PLWHV, which is associated with perception towards the vaccine. The study adopted a cross-sectional, descriptive research design to assess the perception of PLWHV towards the COVID-19 vaccine. The study revealed that most respondents believe that getting the COVID-19 vaccine will protect themselves, their families, or their patients (87.3%) and that it will help prevent the transmission of the disease (83.9%). There is also a large percentage of respondents who believe that the vaccine is effective (77.1%) and safe (82.6%) and that it confers long-term immunity

Introduction Job loss and job insecurity were among the topics that were of most concern as consequences of the worldwide spread of the coronavirus. Export-dependent economies and economies that rely on tourism have struggled adjusting to fluctuating and shifting demand. The World Travel and Tourism Council suggested that the global job market was at risk for 75 million people in 2020 [1], while the World Economic Forum reported that the lockdown and layoff practices during the COVID-19 pandemic resulted in 114 million job losses in 2020 [2]. Even employees who survive the layoffs become anxious about their career and suffer high levels of job insecurity [3,4]. According to prior studies, job insecurity is a significant hindrance-related stress that negatively influence tourism business's ability to achieve its desired work [4][5][6] and can lead to absenteeism and anxiety [7]. As a result of the COVID-19 pandemic and according to social cognitive theory, employees who face job insecurity in addition to increased family financial strain are more likely to use moral disengagement practices to disable moral self-regulation, resulting in increased levels of unethical behavior. Moreover, researchers asserted that the heavy losses suffered by business organizations created significant unethical organizational practice [3,8,9]. Approximately 90% of companies indicate that COVID-19 is a risk to ethical behavior at work, according to a report from Ernst and Young [10]. Similarly, in a survey conducted in India by Bhattacharyya [11] during the COVID-19 outbreak, many employees were found to be willing to engage in unethical behavior, such as falsifying records of customers and disclosing false information to their managers . Researchers have recently been interested in researching the reasons behind unethical practices during the COVID-19 pandemic and understanding the relationship with job loss and perceived job insecurity. For example, guided by appraisal theories of emotion, Hillebrandt and Barclay [4] argued that COVID-19 provokes anxiety and can drive employees to prioritize their self-interest and promote cheating behavior in workplace. Elshaer and Azazz [3] surveyed 650 employees working in the Egyptian tourism industry to explore the psychological process that would drive unethical organizational behaviors by employees who contend with job insecurity. They found that perceived job insecurity reduces job embeddedness, strengthens turnover intentions, and encourages unethical behavior. In addition, previous studies asserted that employees who suffer from stresses due to workplace threats may conduct UOB as a way to protect their gains and job assets [12,13]. Employees conducting unethical organization behavior can also be driven by self-serving interest to acquire personal gains [14] or benefiting their organization or group [15] while benefiting themselves accordingly [16]. Based on behavioral ethics research, people can generally fail to make an objective assessment of the ethics of their behavior in the workplace [17], since their cognitive biases cause them to underestimate or ignore their unethical behavior. Elshaer et al. [18] added that often, employees do not make an explicit decision to act unethically but rather seek to convince themselves that there is nothing wrong with their behavior. In general, UOB can lead to devastating effects, such as significant financial losses, legal prosecutions, and corporate closures [19,20]. While even simple unethical behaviors in organizations can lead to significant hidden costs, tarnishing employee morale and damaging a company's reputation [21]. Despite the thrive of behavioral ethics research, negative behavior displayed within organizations has such a wide scope that it is virtually not possible to explore within the scope of a few research projects [22], and various studied contexts are needed to unpack the drivers of UOB for mitigating resulting risks. Most previous research on unethical behavior in the workplace focus on unethical pro-organizational behavior [9] with little attention to unethical practices in the name of self-interest [22][23][24] or the family [2,25]. The prevalent unethical behaviors during the COVID-19 pandemic [3] and their possible relations with job insecurity [2] have raised significant questions about the different forms of unethical organizational behavior during crises, the possible psychological process that drive such practices, and how it can be mitigated. Therefore, to address this gap of research and based on theories of conservation of resources, social cognitive and behavioral ethics , the current study aims to further investigate the effect of job insecurity on unethical organizational behavior among employees amid the COVID-19 pandemic, using family financial pressure and family motivation as mediating variables. The results of this study, thus, extend prior research results on conditions that shape unethical practices in the workplace and better explain the widespread UOB during the COVID-19 pandemic. It also provides insights into how organizations can address ethical challenges. --- Theoretical Background and Hypotheses Development 2.1. Job Insecurity and Unethical Workplace Behavior Job insecurity has long been a subject of study in a wide variety of research papers [2,4,26,27]. Numerous studies have been conducted in the hotel and tourism industries, notably on job insecurity and its effect on human behavior [2,28]. Job insecurity is a "perceptual phenomenon" that focuses on a person's current job stability threats [29]. Hellgren et al. [30] proposes two categories of job insecurity: quantitative "threats to the job as a whole" and qualitative "threats to desired job characteristics". Quantitative job insecurity focuses on the expected job loss triggered by intentional or unintentional administrative signals or appraisal reports by employees' supervisors, while qualitative job insecurity illustrates how an individual perceives their future job loss in light of a perceived threat [30]. Given the devastating effects of the COVID-19 pandemic on the economy, downsizing has become a common strategy in recent years. Downsizing is a method of reducing labor costs, streamlining operations, and increasing organizational competitiveness [31]. According to [32,33], organizational restructuring and the downsizing process have proved to threaten workers and their careers, resulting in exacerbating perceived job insecurity [34]. The resulting stresses of perceived job instability may motivate employees to engage in unethical actions that they believe might protect them against the threat of job loss or even keep some important features of their job [23,[35][36][37][38][39]. Unethical workplace behavior may include actions that benefit the organization, group or employee self-interest, such as diminishing colleagues' efforts to improve personal relationships, reputations, and professional success [40]. Employees' activities and behaviors that are in direct conflict with the organization's norms and values may create significant financial losses [41] and jeopardize organizational image [42]. Accordingly, as shown in Figure 1, the below hypothesis is suggested: Hypothesis 1 . Job insecurity has a positive impact on workplace unethical behavior. Job insecurity has long been a subject of study in a wide variety of research papers [2,4,26,27]. Numerous studies have been conducted in the hotel and tourism industries, notably on job insecurity and its effect on human behavior [2,28]. Job insecurity is a "perceptual phenomenon" that focuses on a person's current job stability threats [29]. Hellgren et al. [30] proposes two categories of job insecurity: quantitative "threats to the job as a whole" and qualitative "threats to desired job characteristics". Quantitative job insecurity focuses on the expected job loss triggered by intentional or unintentional administrative signals or appraisal reports by employees' supervisors, while qualitative job insecurity illustrates how an individual perceives their future job loss in light of a perceived threat [30]. Given the devastating effects of the COVID-19 pandemic on the economy, downsizing has become a common strategy in recent years. Downsizing is a method of reducing labor costs, streamlining operations, and increasing organizational competitiveness [31]. According to [32,33], organizational restructuring and the downsizing process have proved to threaten workers and their careers, resulting in exacerbating perceived job insecurity [34]. The resulting stresses of perceived job instability may motivate employees to engage in unethical actions that they believe might protect them against the threat of job loss or even keep some important features of their job [23,[35][36][37][38][39]. Unethical workplace behavior may include actions that benefit the organization, group or employee self-interest, such as diminishing colleagues' efforts to improve personal relationships, reputations, and professional success [40]. Employees' activities and behaviors that are in direct conflict with the organization's norms and values may create significant financial losses [41] and jeopardize organizational image [42]. Accordingly, as shown in Figure 1, the below hypothesis is suggested: Hypothesis 1 . Job insecurity has a positive impact on workplace unethical behavior. --- Job Insecurity, Family Financial Pressure, and Unethical Workplace Behavior Employees as well as their families face financial difficulties as a result of the high percentage of job insecurity [43]. Despite remarkable advances in our understanding of the impact of job insecurity on well-being, stress, and health over the last several years --- Job Insecurity, Family Financial Pressure, and Unethical Workplace Behavior Employees as well as their families face financial difficulties as a result of the high percentage of job insecurity [43]. Despite remarkable advances in our understanding of the impact of job insecurity on well-being, stress, and health over the last several years [30,44], it is difficult to infer causality. Financial stress on the family is likely to exacerbate job insecurity, which in turn leads to financial pressure [45,46]. A few research studies have explored the relationship between job insecurity and employees' financial well-being and pressure and provide contradicting results between significant [47] and insignificant [45] effects. Therefore, the relationship between job insecurity and family financial pressure requires further investigation. Families' financial difficulties are not just felt by the impoverished; they are also felt by rich people who want to maintain pace with their friends. When confronted with strong financial difficulties from family members, an employee's principal purpose is to relieve those pressures. The more pressing the need, the more significant this goal will become. Generally, supporting one's family monetarily is a key worth in human culture [48]. Liu et al. [25] elaborated that social expectations are framed, and laws are laid out to uphold the satisfaction of familial monetary obligations. When stressed to assist their families, employees are bound to consider it to be their responsibility to make any strides important to help their family, subsequently obscuring their moral obligation regarding their actions. Based on the theory of conservation of resources developed by Hobfoll [12], when people face a concern of losing their valuable resources, they become pressured to protect those resources by, for example, acquiring recuperation assets. Accordingly, when employees encounter substantial financial difficulties in their families, they are more likely to concentrate their efforts on obtaining financial compensation from their employer [46]. As a result, self-justification of immoral actions in the workplace can then thrive [49]. Unethical workplace activities may help alleviate the stress and aggravation felt by employees while simultaneously improving the financial well-being of the employees' families. Many sorts of unethical behavior in the name of the family are directly linked to financial advantages that might relieve financial stress, such as bringing organization possessions home for use or accompanying relatives to the workplace to gain benefit from the organization's resources. According to the social cognitive theory proposed by Bandura [50] and the self-concept maintenance theory developed by Mazar et al. [51], the readiness of self-justifications encourages unethical behavior through an expanded moral disengagement. Self-justifications can make the UB looks less immoral; costs of the dishonest action are limited, disregarded, or confounded; or casualties of the wrongdoing are undervalued or accused. In summary, when family financial pressures are increased because of perceived job insecurity, employees may become more likely to participate in unethical workplace behavior to benefit their family and decrease these related stresses. Thus, the following hypotheses were proposed: Hypothesis 2 . Job insecurity has a significant impact on family financial pressure. --- Hypothesis 3 . Family financial pressure has a significant impact on unethical workplace behavior. --- Hypothesis 4 . Family financial pressure mediates the impact of job insecurity and unethical workplace behavior. --- Job Insecurity, Family Motivation, and Unethical Workplace Behavior Supporting one's family is a significant justification for why many people work, yet surprisingly few researchers have investigated the effects of family motivation [47], particularly in relation to perceived pressures and job insecurity. Moreover, Liu et al. [25] noted that no previous study has thoroughly examined the role of the family as a motivating factor for unethical behavior in organizations. Menges et al. defines family motivation as "the desire to expend effort to benefit one's family". Prior research suggested that workers with a high family motive are more likely to prioritize family concerns and perceive the family's best interests as a main consideration [25,46,48]. This would likely drive employees who place a high value on their families to justify immoral behavior in the workplace since it benefits them personally and socially as well as their own families [52,53]. Relatedly, previous studies [53][54][55] explained that employees ted to perceive their desire protect to benefit another party's or beneficiaries' interest as a moral justification for unethical behavior. Based on the concept of bounded ethicality, an employee may often behave unethically as he/she either consciously or unconsciously was able to disregard and justify his/her own misconduct [30]. Accordingly, this study suggests that when job insecurity increases, workers with high family motivation may engage in unethical practices to benefit their family interests and will demonstrate less attention to organizational moral standards. In other words, whether individuals choose to be engaged in unethical organizational behavior that violates the moral code and interests of the firm can be determined by their familial motives. Employees thus become more prone to justify their unethical workplace behavior in order to alleviate their job insecurity: Hypothesis 5 . Job insecurity has a significant impact on family motives. --- Hypothesis 6 . Family motivation has a significant impact on unethical workplace behavior. Hypothesis 7 . Family motivation mediates the impact of job insecurity on unethical workplace behavior. --- Methodological Approach --- Development of Study Measures and Instrument The formulation of the scales in this study was based on an extensive survey of previously employed theoretical items in the literature. This survey creates four factors, each with their own set of items, which are then revised to fit the context of the hospitality industry . The operationalization of the study variables is depicted in Table 1. We use the fundamental processes proposed by Maddox [56] and Churchill [57] to create 21 variables on a standard five-point Likert scale, where strongly disagree is 1 and strongly agree is 5. The items measuring job insecurity were created with a multiitem scale developed by Hellgren et al. [30] and employed by Elshaer and Azazz [3] in the tourism industry. Family financial pressures were operationalized by three variables based on the work of Conger et al. [58] and employed by Elshaer and Azazz [3] in the hotel industry. We adopted the five items of family motivation of Menges et al. [47]; a sample item is "It is important for me to do good for my family". Finally, unethical workplace behavior in the name of the family was measured by seven items derived from Liu et al. [25]; a sample item is "I took advantage of my position in the company to make things more convenient for my family". The questionnaire was formerly in English; then, the back-translation approach was adopted [59]. Three qualified academics translated the research questionnaire from its original language to respondents' language . Furthermore, another three academics conducted the back translation from respondents' language to English. The resulted revealed that the two versions were the same and consistent with no differences. Using extensive pre-testing and piloting stages, the research instrument was internally validated with input from six academics and fifteen employees in the field of the hospitality industry. The pilot participants indicated the measures' high consistency and face and content validity. The final instrument was administered to 1000 employees working in five-star hotels and travel agents in greater Cairo, Egypt. --- Process of Collecting Data The study data were gathered in a three-waves process from 30 five-star hotels and 35 travel agents classified as category A in greater Cairo, Egypt. It was decided to use the three-wave approach, with at least a one-month period between each wave, in order to reduce the probability of common method variance [60]. Participants in the first wave provided information about their demographics as well as their perceptions of job insecurity. After one month , participants who had completed the first wave were surveyed regarding unethical workplace behavior in the name of the family. After one more month , those who completed both the W1 and W2 surveys answered questions about family financial stress and family motivation. To ensure that the data collected in all three waves came from the same respondents, a coding system was used. The participants were chosen with the help of the hotels/travel agencies mangers who agreed to let us use their staff lists for scientific purpose. A total of 1000 non-managerial employees were randomly chosen to participate in the three waves of the survey process; replies were obtained from 890, 800, and 770 people, respectively, demonstrating response rates of 89%, 80%, and 77%, respectively. --- Results --- Descriptive Statistics Of the 770 who completed the questionnaires in the final third wave, 70% were male. Ten percent of those who responded in the final wave were between the ages of 18 and 23, 15% were 24-29 years old, 25% were 30-35 years old, 30% were 36-41 years old, and 20% were above 42 years old. In terms of education, 50% of the participants achieved high school level, 30% obtained a college degree, and 20% had a bachelor's level or above. Regarding work experience, 30% of participants had experience for one year or less, 40% had work experience of two to three years, while participants who had work experience for more than five years accounted for 15% of the total targeted participants. The variables mean ranged from 3.46 to 4.13, while the items' standard deviation scores were from 0.649 to 1.293, suggesting that the study data are more distributed and less gathered around its mean value [61]. The skewness and kurtosis scores are not exceeding -2 or +2, suggesting that the study data have satisfactory normal distribution [62]. Furthermore, as depicted in Table 1, variance inflation factors scores for all items were below 0.4, which confirm that multicollinearity is not an issue in our study [63]. --- Measurement Model Assessment For construct reliability and validity, we used confirmatory factor analysis to combine all dependent and independent unobserved latent variables into a single CFA model that showed a satisfactory model fit: model fit: χ 2 = 489.891, p < 0.001, normed χ 2 = 2.677, RMSEA = 0.031, CFI = 0.977, TLI = 0.978, NFI = 0.977), as depicted in Table 2 [61,64]. We examined the composite reliability and discriminant validity of our constructs using the estimates from this model [65]. Measuring the construct validity was completed by examining convergent and discriminant validity for each construct. To test the convergent validity of the factors, Table 2 shows that all factor loadings for our constructs' items are statistically significant at the 0.001 level and exceed the minimum criterion of 0.5. Second, the average variance extracted for all research constructs is greater than 0.5. Finally, the construct reliability scores for all the employed four factors-job insecurity , family financial pressure , family motivation , and unethical workplace behavior in the name of the family -exceeded the recommended 0.70 cut-off point. Thus, as Anderson and Gerbing [64] and Hair et al. [62] recommend, our CFA output results revealed that all research constructs have a high satisfactory level of convergent validity. The discriminant validity of constructs was assessed using Cronbach alpha values, correlation matrixes, and the square root of AVEs, as recommended by Fornell and Larcker [65]. Table 2 showed the correlation matrix, composite Cronbach alphas, and AVE values of the research four factors. As displayed in Table 2, bold diagonal values are larger than off-diagonal values , which support a satisfactory discriminant validity for research factors as advocated by Fornell and Larcker [65]. Finally, the AVE values for all the four factors surpass the maximum shared values , further supporting a satisfactory level of discriminant validity. Overall, our measurement model demonstrates satisfactory levels of composite reliability and discriminant validity, according to the previous findings. --- Structural Model Assessment Following the establishing of confidence in the adequacy of the employed measures, we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation. The evaluation of the hypothesized model is confirmed through two main criteria: the overall model goodness of fit using the recommended indices such as x 2 /df, TLI, CFI, RMR and RMSEA and the statistical significance level for the models' hypotheses. As shown in Table 3, the GoF measures for the structural model yielded satisfactory results. Additionally, the results of the anticipated model are illustrated in Figure 2 and Table 3. The interrelationship in the suggested model contains seven justified hypotheses that investigate interactions among the research latent variables. The SEM analysis revealed that all seven hypotheses are significant at a statistical p-value less than 0.05. Hypothesis 1 investigated the direct effect of job insecurity on unethical workplace behavior in the name of the family, which was supported with a path coefficient of 0.21, demonstrating that the two variables have a positive direct relationship. Likewise, the SEM analysis revealed that the job insecurity significantly and positively affects family financial pressure with a path coefficient of 0.39, thus supporting hypothesis number 2 . Additionally, in line with our proposition, the effect of family financial pressure on unethical workplace behavior in the name of the family was found to be significant and positive with a correlation coefficient of 0.45, therefore supporting hypothesis number 3 . Furthermore, as proposed, hypothesis number five tested the impact of job insecurity on family motivation, and the analysis gave signals of a positive and significant association between the two factors with a correlation coefficient of 0.37, thus supporting hypothesis number 5 . Finally, as proposed in hypothesis number 6 , the impact of family motivation on unethical workplace behavior in the name of the family was found to be significant and positive ; thus, hypothesis number 6 was confirmed. --- Structural Model Assessment Following the establishing of confidence in the adequacy of the employed measures, we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation. The evaluation of the hypothesized model is confirmed through two main criteria: the overall model goodness of fit using the recommended indices such as x 2 /df, TLI, CFI, RMR and RMSEA and the statistical significance level for the models' hypotheses. As shown in Table 3, the GoF measures for the structural model yielded satisfactory results. Additionally, the results of the anticipated model are illustrated in Figure 2 and Table 3. --- Structural Model Assessment Following the establishing of confidence in the adequacy of the employed measures, we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation. The evaluation of the hypothesized model is confirmed through two main criteria: the overall model goodness of fit using the recommended indices such as x 2 /df, TLI, CFI, RMR and RMSEA and the statistical significance level for the models' hypotheses. As shown in Table 3, the GoF measures for the structural model yielded satisfactory results. Additionally, the results of the anticipated model are illustrated in Figure 2 and Table 3. --- Structural Model Assessment Following the establishing of confidence in the adequacy of the employed measures, we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation. The evaluation of the hypothesized model is confirmed through two main criteria: the overall model goodness of fit using the recommended indices such as x 2 /df, TLI, CFI, RMR and RMSEA and the statistical significance level for the models' hypotheses. As shown in Table 3, the GoF measures for the structural model yielded satisfactory results. Additionally, the results of the anticipated model are illustrated in Figure 2 and Table 3. --- Structural Model Assessment Following the establishing of confidence in the adequacy of the employed measures, we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation. The evaluation of the hypothesized model is confirmed through two main criteria: the overall model goodness of fit using the recommended indices such as x 2 /df, TLI, CFI, RMR and RMSEA and the statistical significance level for the models' hypotheses. As shown in Table 3, the GoF measures for the structural model yielded satisfactory results. Additionally, the results of the anticipated model are illustrated in Figure 2 and Table 3. --- Structural Model Assessment Following the establishing of confidence in the adequacy of the employed measures, we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation. The evaluation of the hypothesized model is confirmed through two main criteria: the overall model goodness of fit using the recommended indices such as x 2 /df, TLI, CFI, RMR and RMSEA and the statistical significance level for the models' hypotheses. As shown in Table 3, the GoF measures for the structural model yielded satisfactory results. Additionally, the results of the anticipated model are illustrated in Figure 2 and Table 3. /df, TLI, CFI, RMR and RMSEA and the statistical significance level for the models' hypotheses. As shown in Table 3, the GoF measures for the structural model yielded satisfactory results. Additionally, the results of the anticipated model are illustrated in Figure 2 and Table 3. Table 3. Result of structural model. /df, TLI, CFI, RMR and RMSEA and the statistical significance level for the models' hypotheses. As shown in Table 3, the GoF measures for the structural model yielded satisfactory results. Additionally, the results of the anticipated model are illustrated in Figure 2 and Table 3. --- Hypotheses Table 3. Result of structural model. --- Hypotheses --- Structural Model Assessment Following the establishing of confidence in the adequacy of the employed measures, we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation. The evaluation of the hypothesized model is confirmed through two main criteria: the overall model goodness of fit using the recommended indices such as x 2 /df, TLI, CFI, RMR and RMSEA and the statistical significance level for the models' hypotheses. As shown in Table 3, the GoF measures for the structural model yielded satisfactory results. Additionally, the results of the anticipated model are illustrated in Figure 2 and Table 3. --- Structural Model Assessment Following the establishing of confidence in the adequacy of the employed measures, we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation. The evaluation of the hypothesized model is confirmed through two main criteria: the overall model goodness of fit using the recommended indices such as x 2 /df, TLI, CFI, RMR and RMSEA and the statistical significance level for the models' hypotheses. As shown in Table 3, the GoF measures for the structural model yielded satisfactory results. Additionally, the results of the anticipated model are illustrated in Figure 2 and Table 3. --- Structural Model Assessment Following the establishing of confidence in the adequacy of the employed measures, we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation. The evaluation of the hypothesized model is confirmed through two main criteria: the overall model goodness of fit using the recommended indices such as x 2 /df, TLI, CFI, RMR and RMSEA and the statistical significance level for the models' hypotheses. As shown in Table 3, the GoF measures for the structural model yielded satisfactory results. Additionally, the results of the anticipated model are illustrated in Figure 2 and Table 3. To test hypotheses 4 and 7, suggestions introduced by [62,66] were adopted to evaluate the mediation impact of family financial pressure and family motivation in the relationship between job insecurity and unethical workplace behavior in the name of the family. Specifically, Zhao et al. [66] declared that for "direct-only nonmedication effects", only direct path coefficients should be observed, and that only direct path coefficients should be observed with a significant p-value, while all indirect relationships should not be statistically significant. For "complementary mediation", all direct and indirect correlations should be significant p-value with the same sign. Finally, "competitive mediation" is supported when all relationships are significant but with opposing signs. As pictured in Figure 2, all the tested paths are significant with the same positive sign, as depicted in Table 4. Specifically, the direct relationship between job insecurity and unethical workplace behavior in the name of the family is significant and positive , and job insecurity directly, positively, and significantly, affects family financial pressure and family motivation . In the same vein, family financial pressure was found to have a direct, positive, and significant relationship with unethical workplace behavior in the name of the family . Similarly, family motivation was found to have a direct, positive, and significant relationship with unethical workplace behavior in the name of the family . These results supported the complementary mediation of family financial pressure and family motivation in the relationship between job insecurity and unethical workplace behavior in the name of the family, therefore supporting hypotheses 4 and 7. Furthermore, specific indirect estimates from job insecurity to unethical workplace behavior through family financial pressure was calculated from the SEM Amos output to detect mediation, in which the lower and the upper value generated a significant standardized indirect estimates of 0.303. Similarly, the specific indirect estimate from job insecurity to unethical workplace behavior through family motivation was lower , and the upper value created a significant standardized indirect estimate of 0.326. The previous results further support H4 and H7. Finally, the standardized indirect path coefficient and total effects may also be reviewed in the SEM output to detect mediation impacts [62]. The standardized indirect path coefficients from the job insecurity to unethical workplace behavior in the name of the family via the mediating role of family financial pressure and family motivation increase the direct impact from 0.21 to a total impact of 0.65 . This suggests that unethical workplace behavior in the name of the family increased by 44% via the mediating role of family financial pressure and family motivation. Furthermore, the proposed structural model showed a high level of explanatory power , explaining 52% of the variation in unethical workplace behavior in the name of the family . --- Discussion and Implications The outbreak of COVID-19 has created an opportunity to better understand the relationship between unethical behavior and perceived risk of job insecurity in tourism organizations. Drawing to theories of conservation of resources, social cognitive and behavioral ethics , this study examined family motivation and financial pressure as mediators of the relationship between job insecurity and unethical organizational behaviors. The results provide insights into the reasons behind the increased UOB during the COVID-19 pandemic [2,3,8,9], and they would add to researchers and practitioners understanding of how to address ethical challenges in their organizations. A survey was created and distributed to 770 employees of five-star hotels and Category A travel agencies. To evaluate the proposed structural model as well as the measurement model, two main data analysis methods were used. SEM was used to evaluate the proposed structural model, and CFA was used to evaluate the measurement model's convergent and discriminant validity, respectively. The findings revealed that the measurement model exhibited good convergence and discriminant validity, and that the proposed structural model accurately represented the data. A total of seven hypotheses were proposed and evaluated. The results revealed that job insecurity has a direct impact on unethical workplace behavior in the name of family as well as an indirect impact through financial pressure and motivation imposed by the extended family. The indirect effect increases the total effect of job insecurity on unethical organization behavior in the name of the family by 44%, providing evidence that both family financial pressure and family motivation play a role in mediating the relationship between job insecurity and unethical organization behavior in the name of the family. All endogenous variables combined account for 52% of the variance in unethical organizational behavior to benefit family, according to the findings. These results extend the prior results of Lawrence and Kacmar [38], who found emotional exhaustion as a mediator in the relationship between job insecurity and unethical behavior. This is by highlighting the role of emotional exhaustion that derived from family financial pressures and motivation. Complementing prior research, family financial pressures [25,46] and motivations [9,55] were found to reduce self-regulatory resources and motivate unethical behaviors in the name of the family. The results indicated that participants who suffered high job instability in their workplace experienced higher levels of family pressures and were more prone to practice UOB to benefit their relatives. In support, Zhang et al. [46] articulated that when employees encounter substantial financial difficulties in their families, they are more likely to focus on obtaining financial benefits from their employer. In addition, this study provides empirical support for the argument of Hillebrandt and Barclay [4] that anxiety elicited by COVID-19 may focus employees' attention on their self-related interest and encourage cheating and other unethical behaviors. --- Implications to Theory The result of this study has a three-fold contribution to theory. First, it extends the discussion of previous studies on conditions that shape unethical practices in workplaces. Most previous studies have identified that perceived job insecurity results in UOB that are either for benefiting the organization or self-serving. While this study adds empirical evidence on the important effect of family-related pressures, financial or motivational, on UOB, with particular attention of the influence of these factors when accompanied with job insecurity. Second, this study tries to answer the calls of prior researchers [3,4,22,25,66] to further examine the influence of environmental factors on UOB. The results add to explaining the reasons of the widespread unethical behaviors in organizations encountered during the COVID-19 pandemic. In particular, the current study adds to the understanding of the psychological process that employees may go through in making unethical decisions when faced by job insecurity. It is also the first study to discuss the mediating role of family motivation and financial pressure in the relationship between perceived job insecurity and UOB. Third, this study answers calls to examine the employee's family as a source of motivation to possible UOB [25,46]. Despite previous warnings of its possible strong influence on unethical workplace behavior [46], family motivation has received little empirical and theoretical attention. Instead, most studies have regarded family motivation as a driver of work effectiveness . Therefore, by demonstrating the role of family motivation in triggering unethical workplace behavior, this study extends research knowledge about possible psychological aspects that fuel UOB. At the same time, it gives insights to the possible dual role of family motivation as a source of desirable and undesirable organizational actions . --- Implications to Practice The tourism industry was the most affected during the COVID-19 pandemic. The large seen shutdowns and layoffs during the pandemic and their effect on employee's psychology and behavior would have a long-lasting difficult influence on tourism workplaces and hospitality industry if not well understood and dealt with by decision-makers. Although the influence of COVID-19 on job loss and job insecurity has received much attention in recent tourism and hospitality research, a more comprehensive picture of the detrimental effect of job stress and anxiety on employee's behavior still needs to be explored to better inform tourism decision-makers [9,23]. In this regard, this study contributes to the understanding of why the COVID-19 pandemic has induced UOB in the tourism industry and highlights the role of job insecurity and family pressures and motivation in increasing UOB in the name of the family. This would inform tourism decision-makers and managers toward preventing unethical behavior and the possible damaging consequences on financial performance and reputation. Decision-makers should strive to advocate social messages and enact policies that reduce employees' perceived job insecurity, since this is a gateway to UOB. In addition, based on the concept of bounded ethicality, the current study asserted that ambiguous circumstances may veil the ethical aspects of employee's decisions, as people lean to self-justification of their immoral actions in the workplace [17,18,67]. Therefore, pressures of job loss may drive even honest employees to engage in minor dishonesty and simultaneously stay ignorant of the ethical repercussions of their acts [18,68]. Thus, with this in mind, organizational managers need to carefully observe the actions of all employees and regularly provide moral reminders, which can be a useful tool to reduce or prevent UOB. Organizations also should assess the ethical development of employees, promote moral actions and punish for unethical behavior. --- Conclusions, Limitations, and Further Research The prevalent and costly unethical practices in workplaces and their different types have attracted recent research attention, especially during the COVID-19 crises. This study investigated a neglected yet important form of UOB: unethical organizational practices in the name of the family. It proposed a model that may assist academics and practitioners in better understanding of how perceived job insecurity influences UOB through the mediating effect of family financial pressure and family motivation. The results revealed that perceived risk of job insecurity predicts employees' engagement in UOB, while intentions of unethical behaviors increase by high family motivation and financial pressures. However, this study has some limitations that offers opportunities for future research papers. The current results of the analyzed data showed that family motivation and financial pressure partially mediated the impact of job insecurity and unethical workplace behavior. To further our understanding on the relationship between job insecurity and UOB, future research papers can investigate more mediating variables that can affect the relationship between job insecurity and unethical workplace behavior in the name of the family. Moreover, future studies should investigate possible boundary conditions such as moral identities and religious commitment, since previous studies, for example, revealed that moral identity undermines the strong influence of the self-control depletion on dishonesty and unethical practices [69]. Although this study ensured the confidentiality and anonymity of the questionnaire for the participants, the self-reported survey used in this study may encourage participants to biases their answers, since questions were about unethical actions to benefit the family. Thus, future studies can allow peer evaluation through colleagues or supervisors for more objectivity. In addition, future research can address the practices of decision makers to diminish UOB for family benefit and suggest methods that can be followed to control unethical practices. Furthermore, the collected data were cross-sectional; therefore, causal association between latent variables cannot be completely confirmed, and it is recommended for future investigations to collect longitudinal objective data or a different data source to validate the study model. Finally, a multigroup analysis approach can be conducted in future studies to validate and compare the results of the current study with data collected from different context [70]. Finally, it is important to highlight that the current study explores the relationship between family pressure and unethical workplace behavior under job insecurity. Accordingly, the UOB examined is not general but rather related to the benefit of the family. Future research would need to study general and other specific unethical behaviors that prevail in times of crisis and apply them to different contexts to understand how prevalent UOB is and how to mitigate its undesired consequences. --- Data Availability Statement: Data are available upon request from researchers who meet the eligibility criteria. Kindly contact the first author privately through e-mail. --- Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the deanship of scientific research ethical committee, King Faisal University . Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. ---

In organizations, unethical behaviors are pervasive and costly, and considerable recent research attention has been paid to various types of workplace unethical behavior. This study examines employees' behaviors that are carried out for the benefit of one's family but violate societal and organizational moral standards. Drawing upon the self-maintenance and bounded ethicality theories, this study examines the engagement of unethical organization behaviors (UOB) in the name of the family during the COVID-19 pandemic. It examines the influence of job instability and the mediating role of family financial pressure and family motivation. A total of 770 employees in hotels and travel agents in Egypt were targeted, and the data were analyzed using structural equation modeling. The results posit that perceived risk of job insecurity predicts engagement in unethical organizational behaviors, while intentions of UOB increase by high family motivation and financial pressures. Toward the end of this paper, a discussion on the theoretical and practical implications and are presented.

Introduction Theoretical models of family economic stress have long associated socioeconomic hardship with risk factors in child and adolescent development, including chronic experiences of stress and diverse indicators of poor psychosocial well-being . More specifically, socioeconomic stress has been consistently linked to adolescents' academic adjustment, with low family income conferring disadvantages in school achievement and success . Although a relatively large body of literature has established such maladaptive links, aside from a few exceptions , prior research pinpointing negative effects of socioeconomic stress on academic outcomes predominantly has focused on adolescents from European American and African American backgrounds to the exclusion of adolescents from immigrant backgrounds, and particularly those with Asian ancestry. Our work extends the current literature on how socioeconomic stress shapes adolescents' lives by focusing on an understudied sample of Asian American youth; using a risk and resilience framework to not only document negative effects of socioeconomic stress on academic adjustment but to also identify family obligation as a potentially protective factor in adolescents' lives; and comparing direct and interactive effects of socioeconomic stress and family obligation at two different developmental periods, namely, during the early years of high school and again in adolescents' later high school years. By identifying risk and protective factors associated with academic adjustment, and considering developmental differences related to family processes, we can extend existing knowledge and ultimately determine ways to best foster Asian youths' adjustment. --- Socioeconomic Stress Among Asian American Youth Immigrant youth from under-researched Asian backgrounds represent a particularly interesting case for studying both socioeconomic stress and academic adjustment given that the model minority stereotype presumes that each of these areas are highly relevant to their group, but not especially problematic . In terms of socioeconomic status, a common misperception is that Asian families are generally well-adjusted and do not suffer from financial hardships as much as families from other ethnic minority groups. Official accounts do suggest that Asian American households report a relatively high median income . However, these average income levels do not preclude the fact that socioeconomic stress, if experienced, can still negatively impact outcomes. Moreover, it is important to note that these same federal reports also suggest that 12 % of Asian American families live below the poverty line, which is actually similar to the rates found among non-Hispanic whites. It is also critical to acknowledge that individuals from Asian backgrounds represent a highly diverse panethnic group and the degree to which each family experiences socioeconomic adversity likely depends on factors such as specific country of origin, individual reasons for immigration, and refugee or citizenship status. As one example of such ethnic variability, recent reports document a substantial difference between the yearly median income for South Asian Indians and Bangladeshis . Hence, rather than assume that socioeconomic stressors are not universally salient for Asian American families, it seems critical to examine how financial struggles can in fact influence these adolescents' lives and ultimate adjustment. There are a variety of reasons to expect adverse associations between socioeconomic stress and adolescents' academic outcomes. Drawing from research with other ethnic minority groups, poverty can influence cognitive and socioemotional functioning, which have direct repercussions on school achievement . A number of indirect influences also can be seen. For example, socioeconomic stress might contribute to adolescents' feelings of distress or hopelessness, as well as family conflict, which can then have indirect effects on children's academic commitment and success . Family economic stress also might require adolescents to assist their families or work at a part-time job thereby potentially interfering with their academics . Collectively, based on prior research that has identified both direct and indirect effects of socioeconomic stress, we anticipated that, for Asian American youth, experiencing more stress would be related to lower academic adjustment. We considered a range of academic outcomes to demonstrate the diverse implications that socioeconomic stress can have on adolescents' development. The academic arena itself plays a particularly prominent role in the lives of Asian youth. Children from immigrant families are often socialized to believe that education is a major key to economic mobility; hence, among these families there tends to be a strong emphasis on school achievement . Similarly, for many immigrant youth, excelling in school might be perceived as one way to help their family succeed and ultimately achieve the "American Dream" . Given the cultural importance of education among Asian immigrant families, identifying possible obstacles or risk factors in adolescents' academic success is crucial; yet, this group in particular is often overlooked in terms of resources and concerns over academic adjustment. Referring again to the model minority myth, these cultural stereotypes might come into play in the wrongful assumption that most Asian youth are largely high achievers, hard workers, academically motivated, and well-adjusted . There are numerous implications in terms of having to face such a stereotype , and most relevant to the current study is the fact that some adolescents may be mistakenly ignored in terms of the academic and other struggles that they actually encounter. We thus address these pressing concerns and notable gaps in the literature by explicitly focusing on both socioeconomic stress and academic outcomes among Asian youth, and identifying family obligation as a putative moderator of such stress. --- Family Obligation as a Protective Buffer A resiliency framework pinpoints specific features that protect against risk and encourage healthy adjustment, adaptation, and social and psychological competence despite stress or adversity . In the face of socioeconomic stress, what resiliency factors might counteract any negative effects and promote healthy outcomes? Paradoxically, family financial stressors might present youth with a greater need to help out around the house and assist their families as best they can which could then lead to positive outcomes. Indeed, a familistic orientation and positive attitudes toward family obligation, which can be broadly defined as values and expectations regarding family assistance and support, have been implicated as culturally-protective factors in youth development, perhaps because they promote social support and close family relationships . Assisting one's family might also contribute to internal feelings of purpose or meaning, which could then permeate other forms of achievement or academic goals . Family cultural values are particularly relevant to Asian youth . Prior research has found that Asian Americans report high levels of family obligation and often view school success as one of the most important and meaningful ways that they can assist and help their families advance, socially and economically . In the literature, positive links between family obligation and adolescents' academic outcomes have been demonstrated among diverse immigrant samples . Moderating effects also have been found. For instance, among Latinos, who also tend to report strong familistic connections, family obligation buffered adolescents from negative effects of stress on risky behaviors and depression . Although economic stress was included in their conceptualization of risk, academic adjustment was not examined as an outcome. Taken together, based on prior research supporting the benefits of family obligation , we similarly expected to find positive associations between these family attitudes and academic outcomes. Although, to our knowledge, family obligation has not yet been examined as protective factor in terms of the detrimental effects of socioeconomic stress on academic adjustment, we also expected that family obligation would act as a resiliency factor and weaken the negative impact of socioeconomic stress. Furthermore, one additional layer of complexity that we explored was whether associations among socioeconomic stress, family obligation, and academic outcomes might vary based on adolescents' developmental status . --- Developmental Considerations Longitudinal associations between adolescents' experiences of socioeconomic stress and their academic achievement have been documented . However, rather than model change over time, multiple waves of data can be used to determine whether direct and interactive effects of socioeconomic stress and family obligation are more or less relevant to the same youth but at different times in their lives. In terms of academic outcomes, we might expect a developmental shift in the salience of educational aspirations and importance attributed to academics as youth more seriously contemplate their pending high school graduation and plans for the future. The developmental context of late high school would then differentially influence the relationship between socioeconomic struggles, family obligation, and these academic outcomes, especially as youth have to make decisions about whether to stay home, enter the workforce, or go to college. In contrast, the developmental context of younger high school students could be more concerned with the transition to high school and focus less on pressing graduation concerns. Moreover, younger adolescents might also be more limited in the actual support that they can readily provide to their families . Some empirical work does support differences in the extent to which socioeconomic stress affects development. Educational disparities associated with family income and backgrounds tend to increase as students advance in school . Other studies argue that family economic conditions in early and middle childhood are more important for shaping ability and achievement than are economic conditions during adolescence , perhaps because family socioeconomic status tends to increase as children get older. To shed light on these key and competing developmental concerns, we used our data to determine whether the effects of socioeconomic stress and family obligation on academic adjustment are different for adolescents when they are in early versus late high school years. Given our range of outcomes included, we also explored whether the impact of developmental stage would be particularly strong for those outcomes focused on the future compared to more immediate concerns . --- The Present Study The present research seeks to examine whether socioeconomic stress hinders adolescents' academic outcomes, as well as to identify family obligation as a possible moderator of any negative effects. Based on prior research , we expected that socioeconomic stress would be associated with lower academic adjustment among our sample of adolescents from Asian American backgrounds. Consistent with recent work that points to positive benefits of family obligation , we expected that family obligation would be linked positively to academic adjustment, both directly and via moderation against negative effects of socioeconomic stress. We also explored whether direct and interactive associations found are consistent across different periods of development, namely, for adolescents who are in the earlier versus later years of high school. We contribute to the literature by examining understudied Asian American youth, considering multiple indices of academic outcomes, and using two waves of data to explore developmental variations in effects. In addition, previous research commonly has measured socioeconomic stress according to variables created from family income, parental education, and/or parental occupational prestige . Rather than rely on such proxies, we used a more direct measure of family economic strain as our primary independent variable. --- Methods --- --- Procedures Using a stratified sampling procedure, public high schools in the Southeastern U.S. were targeted for recruitment. Adolescents were ultimately drawn from six schools that varied in terms of academic achievement and ethnic diversity. For initial recruitment, all 9th-10th grade students who were identified through school enrollment forms as Asian were convened in small groups and invited to participate in a study on their culture and daily lives. Parental consent and adolescent assent forms were distributed. Researchers returned for a follow-up visit and those students who returned their forms were given a packet of questionnaires, which took about 35-40 min to complete. Upon completion, adolescents were given instructions and materials for a two-week daily diary study, not reported on here. At the end of the daily diary period, researchers returned to schools to collect materials and to give adolescents $25 for participating. Adolescents were asked to participate in follow-ups in consecutive years that consisted of the questionnaire packet only. The current study focuses on data collected in the first wave of the study, when students were in 9th-10th grades , and two years later when students were in 11th-12th grades . Data for the follow-up were collected during school visits and students who were absent or no longer enrolled in the school were sent questionnaires through the postal mail. Approximately 87 % of the original sample was retained in W2, and these participants did not differ from those who participated only in W1 on any demographic or key study variables, using a p < .01 cutoff given the number of tests run. In W2 of the study, adolescents were given $15 for participating. --- Measures Socioeconomic Stress Socioeconomic stress was measured using an index of family economic strain or financial insecurity . On a 0 = no to 1 = yes scale, adolescents were asked to indicate whether their families experienced economic stressors. We included five items . Adolescents were instructed to think about the past 12 months in their responses. Responses were summed across all items. The internal consistencies found in the present study were .67 and .69 at Waves 1 and 2, respectively, which are similar to those found in prior research on adolescents . --- Family Obligation A 12-item scale was used to assess adolescents' attitudes toward family obligation and the provision of family assistance ). Adolescents were asked to determine how important each item is on a five-point scale ranging from Not At All Important to Very Important with higher scores reflecting higher family obligation. Sample items include, "Help take care of brothers and sisters," "Run errands that the family needs done," and, "Help out around the house." Items concerning attitudes toward future support and obligation were also presented using a six-item scale. Samples include, "Help your parents financially in the future," "Spend time with your parents even after you no longer live with them," and, "Help take care of your brothers and sisters in the future." Following prior research , both scales were combined and averaged to reflect an overall index of family obligation . --- Self-Reported Grade Point Average Adolescents were asked to write-in their current Grade Point Average. Although a recent metaanalysis suggests that self-reports of GPA may be systematically inflated and should be used with caution, they still generally predict outcomes to a similar extent as actual GPA . Indeed, as shown in Table 1, patterns of association between our measure of GPA and other academic outcomes were as expected. Further, in a follow-up study in which school reports of GPA were collected on a small subset of this sample , self and official reports of GPA were significantly correlated . However, due to some missing data and undecipherable responses , analyses with this variable were conducted with a more limited sample. [Table 1 Omitted] --- Importance of Academic Success Importance of academic success was assessed through a six-item scale asking adolescents to place importance on doing well and succeeding in school. This measure was based on research from Eccles and has been used successfully in prior work . On a scale ranging from 1not important to 5 very important, students reported how important the following things are to them: that you do well in school, that you get good grades, that you get an 'A' on almost every test, that you go to college after high school, that you be one of the best students in your class, that you go to the best college after high school. Items were averaged and the internal consistencies were .85-.86. --- Educational Aspirations and Expectations Also drawn from Eccles , to assess educational aspirations, adolescents were asked, "How far would you like to go in school?" Response options were 1 = finish some high school, 2 = graduate from high school, 3 = graduate from a 2-year college, 4 = graduate from a 4-year college, 5 = graduate from law, medical, or graduate school. One item was similarly used to assess educational expectations. Adolescents were asked, "How far do you think you actually will go in school?" Identical response options as for educational aspirations were used. --- Results --- Preliminary Analyses Bivariate correlations among primary study variables are shown in Table 1, stratified by study wave. As shown, in both earlier and later years of high school, high socioeconomic stress was consistently associated with poor academic outcomes, as defined by all four indices of GPA, importance of academic success, and educational aspirations and expectations. In both waves of the study, family obligation was positively associated with adolescents' reported importance of academic success. In wave W1, family obligation was also linked with higher educational expectations, although this association was only marginally significant. In W2, family obligation was significantly associated with higher educational aspirations. As would be expected, all academic outcome variables were significantly associated with each other. Remaining relations, though not statistically significant, were in expected directions. Means and SDs are also shown in Table 1. Variable means appeared to be generally stable over time. In W2, significantly higher levels of socioeconomic stress were reported [t = -2.21, p < .05] compared to W1. Higher GPA at W2 was also reported [t = -2.58, p < .05]. Remaining means did not significantly vary across the two waves of the study [ts = 1.38-1.92, ns]. Each measure at W1 was significantly correlated with measurements at W2, which further suggests temporal stability among the constructs. These correlations ranged from .47 to .69, p < .001. --- Main and Interactive Effects of Socioeconomic Stress and Family Obligation on Adjustment To examine main and interactive effects of socioeconomic stress and family obligation on adolescents' academic adjustment, a series of hierarchical multiple regressions were conducted. Main effects of socioeconomic stress and family obligation were entered first, followed by their interaction. Variables were centered before creating the interaction term. Gender was also entered in the initial step as a covariate given that prior research has documented gender differences in academic adjustment among Asian American youth . Regressions were conducted separately for each outcome and within W1 and W2. --- Early High School Results for W1 are shown in Table 2. As expected, and consistent with bivariate correlations, socioeconomic stress was negatively associated with all four academic adjustment outcomes. Main effects of family obligation were also found in terms of positive links with importance of academic success and educational expectations. These initial models accounted for 11-15 % of the variance in outcome variables. No other main effects or interactions were found, but an interaction between socioeconomic stress and family obligation approached significance in terms of adolescents' importance of academic success. [Table 2 Omitted] --- Late High School Table 3 illustrates regression results from W2 of the study. Again, main effects of socioeconomic stress were found for all four adjustment variables. Main effects of family obligation were also found with respect to importance of academic success and educational aspirations. With the exception of GPA, the initial models themselves were significant, explaining between 9 and 18 % of the variance in adjustment. In addition, three interactive effects were found. [Table 3 Omitted] Specifically, as shown in Fig. 1, strong attitudes toward family obligation protected youth from the negative effects of socioeconomic stress. Simple slopes analyses suggested that experiencing socioeconomic stress was associated with lower importance of academic success, but only for adolescents who reported low levels of family obligation . For adolescents who indicated strong importance towards helping and assisting their families, the association between socioeconomic hardships and academic importance was not statistically significant . Similar buffering effects were found for educational aspirations and expectations . Although simple slopes for adolescents who reported both high and low levels of family obligation were significant, the effect of socioeconomic stress on aspirations appeared stronger for adolescents with low compared to high endorsements. In terms of expectations, the effect of socioeconomic stress was statistically significant for adolescents who reported low levels of family obligation , but not for those with high obligation , which again supports the protective role of family obligation on adolescents' academic adjustment. [Figure 1 Omitted] [Figure 2 Omitted] [Figure 3 Omitted] --- Discussion The impact of socioeconomic stress on the adjustment of adolescents from Asian American backgrounds has not been a topic of much attention, especially when compared to research focusing on these themes among other ethnic groups. The primary aim of the current study was to address this gap in the literature by examining whether experiencing family financial hardship is associated with poor academic adjustment, widely measured through multiple outcome variables including GPA, importance of academic success, and educational aspirations and expectations. In the face of these negative influences, we also were interested in pinpointing family obligation as a possible buffer and considering whether main and interactive effects of socioeconomic stress and family obligation might developmentally vary over time. In line with prior research with other ethnic groups , we found that socioeconomic stress is indeed a significant risk factor in Asian American adolescents' academic outcomes. Although average levels of socioeconomic stress were relatively low for the sample as a whole, more experiences of household financial stress were associated with lower self-reported GPA, lower valuing of academic success, and lower educational aspirations and expectations. These negative associations were consistent for adolescents in both early and late high school years. It thus appears that socioeconomic struggles can be critical issues for American adolescents with Asian ancestry, who are often widely presumed to be the model minority and generally well-adjusted . Notably, gender also had a main effect on several academic outcomes, which is consistent with prior work that points to females faring better than males in the academic arena . Providing some resilience in the face of stress, we found family obligation to act as a positive resource in adolescents' lives. Direct effects were found whereby family obligation was associated with various indicators of positive academic adjustment in both early and later years of high school. These results are congruent with previous research documenting the virtues of family obligation , and positive links between family obligation and academic outcomes more specifically . Moreover, in the later high school years, family obligation buffered the negative effect of socioeconomic strain on adjustment variables such as importance of academic success and educational aspirations and expectations. More specifically, the academic risks that were associated with socioeconomic stress were attenuated in older adolescents who endorsed the importance of family assistance compared to those who reported low levels of family obligation. Although these results demonstrate that family obligation can serve as a resiliency factor in helping older adolescents deal with the negative effects of socioeconomic stress, several unanswered questions remain. For example, one important topic for future research is to explore whether the protective effect of family obligation also extends to other negative experiences . Similarly, do the positive effects of family obligation generalize to adolescents' from diverse ethnic groups? Our focus on an Asian sample was important in addressing a dearth in the literature, but also limits the generalizability of our results. Constructs of family assistance and closeness might be especially meaningful to adolescents from Asian backgrounds , but whether or not its benefits are equally noteworthy among other samples, particularly in light of protecting against socioeconomic stress, remains largely unknown. Notably, recent evidence does point to family obligation as being associated positively with academic adjustment among both European American and Chinese adolescents , and as an effective moderator against stress among Latino samples . More work along these themes would be informative. The specific mechanisms by which such family cultural values have a positive effect are also unclear. Perhaps helping to maintain family functioning and generally assisting one's family promotes family closeness, which is beneficial in and of itself . Alternatively, it is possible that family obligation affects other areas in adolescents' lives which can then protect against risks to achievement and boost academic success. In line with this idea, recent research suggests that daily acts of family assistance is directly related to adolescents' purpose or meaning in life . Such purpose could then help to promote adolescents' academic aspirations, goals, and achievements, despite their experience of obstacles that might thwart those positive outcomes. Developmentally, moderating effects of family obligation were only found for adolescents in later years of high school. In fact, although the interactions between family obligation and socioeconomic stress among early high school students were not statistically significant, several of the interaction terms were in opposite directions compared to those found in later high school. One explanation for these differences is that family obligation tends to become increasingly salient as adolescents mature, are able to take on more responsibilities, and gain more practical ways to assist their families . For example, although virtually all children can help with various household chores, it is not until the later years of high school that children can drive, which may make it easier to run errands for the family, take on an afterschool job, or engage in more diverse assistance behaviors. It is also possible that, with impending high school graduation, issues such as socioeconomic stress and family obligation are in the forefront of adolescents' lives and come together in more marked ways to impact their academic adjustment. A third explanation is that socioeconomic stress may interact with family obligation differently when it is experienced at a more chronic level. By the time adolescents reach the later years of high school, they presumably have had a longer opportunity to experience socioeconomic stress and it is thus possible that these experiences of chronic stress differentially interacted with family obligation to predict academic outcomes. Notably, average levels of socioeconomic stress were also significantly higher in later years of high school than in earlier years. These mean differences could be potentially due to older adolescents being more aware of their family's financial situations, and perhaps the moderating effect of family obligation does not become relevant until adolescents gain such awareness and/or socioeconomic stress reaches a certain threshold. It is also notable that interactive effects were not found for GPA, which could have been due to limitations in self-reports of the construct or the idea that the interactive effects of socioeconomic stress and family obligation are more salient for academic outcomes that are more future-oriented rather than those that are more immediate in nature. Clearly, more research is needed to better disentangle the differential developmental patterns that we found. Although the focus of this article was on concurrent reports examined at two different developmental periods, multiple waves of data also can be used to investigate longitudinal associations among constructs. For example, using our data in a different way, we conducted post hoc analyses to help shed light on the developmental differences that we found. We ran a series of regressions using W1 reports of socioeconomic stress and family obligation to predict W2 outcomes, after controlling for outcomes at W1. With the exception of one interactive effect that approached significance in terms of GPA , and one main effect of W1 socioeconomic stress predicting importance of academic success at W2 , no other main effects or interactions were found. Given that early reports had little influence on later outcomes, these results confirm our overall findings that suggest that socioeconomic and family constructs are more salient in later versus earlier years of high school. These results also suggest that family stress and resilience processes function in a more temporally proximal manner rather than over time, which supports our initial framework in examining the immediate impact of family obligation and its relevance across differential phases of development. It was somewhat surprising that socioeconomic stress and family obligation were not correlated with each other. It would be reasonable to expect that more financial hardships would be related to adolescents' obligations to step in and assist their families, either by their working at a parttime job to contribute to family income, or by helping out around the house while parents work. One explanation is that our measure of family obligations assessed attitudes toward assistance behaviors rather than the behaviors themselves. Nonetheless, the fact that these are independent constructs supports the need to further examine how such family attitudes are socialized or learned. Prior work suggests that family obligation is a culturally-based construct that may be tied closely to cultural values and ethnic identity . Perhaps examining ethnic identity development as one potential pathway towards family obligation would be an interesting avenue for future research. Indeed, our results highlight the benefits of cultivating attitudes toward family obligation as a resiliency factor. Determining how individual differences in family obligation develop would be helpful in understanding ways to enhance such attitudes and thus promote adolescent outcomes. Taken together, there are several important implications regarding the main effects found and the manner in which socioeconomic stress and family obligation interacted in predicting academic outcomes. Our results suggest that assuming that Asian Americans adolescents are uniformly on a path to high achievement seems unreasonable and potentially flawed. However, many teachers and other school staff may observe such a phenomenon with Asian youth performing well. To reconcile these perspectives, our findings speak to the possibility that high family obligation, which is often found among Asian youth , helps to compensate for the negative effects of socioeconomic stress and maintain the high achieving stereotype. In addition, given that the actual buffering effects of family obligation did not emerge as statistically significant until the later high school years, future research and intervention efforts that are focused on somewhat younger high school students might allow more of an opportunity to observe adverse effects of low family socioeconomic stress and to subsequently intervene early in order to promote better academic outcomes. Indeed, the model minority stereotype involves a complex interplay between adolescent characteristics and both in-school and out-of-school experiences , and our work contributes to the understanding that Asian youths' school achievement is considerably multifaceted. ---

Socioeconomic stress has long been found to place youth at risk, with low family income conferring disadvantages in adolescents' school achievement and success. This study investigates the role of socioeconomic stress on academic adjustment, and pinpoints family obligation as a possible buffer of negative associations. We examined direct and interactive effects at two time points in the same sample of Asian American adolescents-early high school (N = 180 9th-10th graders; 60 % female) and 2 years later in late high school (N = 156 11th-12th graders; 87 % of original sample). Results suggest that socioeconomic stress is indeed associated with poor academic adjustment, measured broadly through self-reported GPA, importance of academic success, and educational aspirations and expectations. Family obligation was positively related to adjustment, and also was found to buffer the negative effects of socioeconomic stress, but only during adolescents' later high school years. Adolescents reporting more family obligation experienced less of the negative effects of financial stress on academic outcomes than those reporting lower obligation. Cultural and developmental implications are discussed in light of these direct and moderating effects.

Introduction Even the most conservative estimates anticipate that at least 45 million jobs in the EU-27 labor market are directly at risk from the coronavirus disease 2019 disruptions [1]. The outbreak of COVID-19 has had a drastic impact on work at a global scale [2]. Changes in when, where, and how work is completed are profound, evidenced, for instance, by widespread remote work directives [3][4][5]. The extent to which employees can adjust to remote work is crucial for individual outcomes and organizational outcomes . Hence, this study explores factors related to employees' adjustment to remote work practices during the first phases of the COVID-19 pandemic. In achieving the aim of this study, we contribute to emerging research on the impact of the COVID-19 pandemic on work [3,[5][6][7][8]. In line with Raghuram et al. [9], we view adjustment to remote work as an overall state of adaptation to environmental demands and conditions. Several critical indicators of adjustment to remote work have been identified, including employees' satisfaction with remote work conditions, perceived job performance as a consequence of remote work, and the ability to balance work and non-work demands [9,10]. In contrast to previous investigations of adjustment [9], the COVID-19 crisis required organizations and their employees to abruptly change their work environments and ways of working. As such, there is a need to understand what factors are related to employees' adjustment to remote work during this crisis [6]. Based on the theory of work adjustment [11,12] and previous work on individual adjustment in a work context [10,13] and adaptation to virtual work [9], we identify and examine a framework of environmental factors that may affect individual adjustment to remote work during the COVID-19 pandemic. Specifically, based on cross-sectional survey data, we provide empirical insights into the extent to which employees' adjustment to remote work is associated with structural factors , relational factors , and contextual factors . Furthermore, we investigate moderating factors ) that potentially influence the relationships underlying employees' adjustment to remote work. Organizational communication quality has been found to be pivotal when dealing with uncertainty and crises, including organizational responses to the COVID-19 pandemic [14]. At the same time, technological advances have been heralded for their ability to facilitate work across spatial distances and both synchronous and asynchronous collaboration [15][16][17][18]. Hence, we investigate the role of organizational communication quality and CTU in qualifying the impact of structural, relational, and contextual factors on adjustment to remote work. Remote work settings involve temporal and spatial dispersion and depend on CTU to allow employees to interact across these boundaries [19][20][21][22][23]. Remote work is defined as "work done by an individual while at a different location than the person directly supervising and/or paying for it" [24] . In the context of the COVID-19 pandemic, this location was typically employees' homes. Although previous studies have indicated that working from home might help employees collaborate across time zones, concentrate better than in the primary work location, and accomplish work tasks [25], it is unclear what factors impact employees' ability to adjust to new demands of their work environment when they are mandated to work from home. We use remote work to refer to the current situation in which employees are mandated to work from home during the pandemic . --- Literature Review and Hypotheses This study takes a work adjustment perspective to examine how employees have adjusted to an abrupt transition to remote work. Adjustment to new work contexts typically involves adaptation to new environmental stimuli or demands. It has been suggested [9] that adjustment to virtual work refers to employees' ability to adapt to virtual work modes as they transition from traditional office environments to remote work. Specifically, adjustment refers to an overall state of adaptation because a transition to remote work highlights the inherent tradeoffs involved in adjustment [9]. Several aspects are considered critical indicators of employees' successful adaptation to a virtual work including satisfaction, commitment, productivity, and the ability to balance work and nonwork demands. Successful adaptation often requires a trade-off between these aspects. To examine the underlying factors that impact employees' adjustment to remote work, we identified several structural, relational, and contextual factors that may impact employees' adaptation . These factors align with those proposed by Raghuram and colleagues [9], but we extend this framework by including crisis-specific concepts such as perceived disruptions and social isolation. Our conceptual model has its theoretical roots in the theory of work adjustment [11,12,26] and in the interactional model of individual adjustment [13]. It identifies several categories of factors relevant to individual adjustment, including in-dividual, job, and organizational factors. Recently, Carillo and colleagues [6] adopted a similar approach to identify the individual, job, and organizational factors underlying telework adjustment in a crisis context. We further extend this work by exploring the role of several moderating factors, including organizational communication quality and CTU. --- Structural Factors Structural factors are the fundamental preconditions and organizational expectations related to a job description that may facilitate or forestall the possibilities to work remotely. Key aspects include work independence and clarity of job criteria [9]. When work can be conducted independently and the criteria for a specific job are clear, employees may be more confident in their ability to complete work remotely, facilitating better adjustment. --- Work Independence Work independence refers to the ability of remote employees to complete tasks without having to engage in continual interaction with their coworkers [27]. Work independence can be facilitated by supporting asynchronous work, for example, allowing access to common databases through technology and ensuring that colleagues can connect with others if needed [9]. Remote employees, who must rely continually on their coworkers, thereby making them reciprocally or sequentially interdependent with others, are likely to experience time pressures, loss of control, and a decline in personal productivity [28,29]. However, independence may facilitate adjustment to remote work [9] because it allows workers to exercise more control over their behavior, for instance, when drawing boundaries between work and nonwork [30] or when enacting discipline to organize their work and apply their skills in an isolated work environment [9]. Hence, employees with greater degrees of independence are found to experience greater adjustment to a remote work context [9]. This is in line with research suggesting that individuals have an innate need for autonomy and self-determination [31,32]. Thus, we propose the following: Hypothesis 1 . Work independence is positively associated with employees' adjustment to remote work. --- Clarity of Job Criteria The clarity of job criteria means that performance assessment at work is perceived as objective, quantifiable, and transparent [9]. Clear and explicit criteria are especially beneficial to guide the performance of remote employees and develop accurate expecta-tions among them [9,30]. This is because remote employees, compared with non-remote employees, have fewer opportunities to seek or receive informal performance feedback or clarifications from their supervisors and coworkers. Unclear evaluation criteria may lead to insecurity and uncertainty concerning work-related expectations. However, when clear and explicit evaluation criteria are in place, remote employees may be even more capable of managing themselves, which may lead to enhanced performance and satisfaction [9,30]. Additionally, clear evaluation criteria can help build mutual expectations and perceptions of procedural fairness and establish perceptions of equity among remote employees who cannot use physical behaviors to compare work outcomes [29,33]. When evaluation criteria are clearly understood, remote employees are also more likely to work on initiatives that are valued by their organization [34]. Hence, we propose the following: Hypothesis 2 . Clarity of job criteria is positively associated with employees' adjustment to remote work. --- Relational Factors Relational factors refer to the social relationships and forms of collaboration within an organization. In the context of remote work, they relate to, for example, support and interpersonal trust [9] among employees working remotely and their supervisors and coworkers. Hence, we examine how trust can help to overcome barriers to adjusting to remote work [9]. In addition, issues of social isolation at work are especially profound during the COVID-19 pandemic; hence, we investigate how these issues may deter adjustment to remote work [35]. --- Interpersonal Trust Because remote work inherently involves physical and psychological distances, factors that create a stronger sense of relationships between coworkers may prevent physical distance from becoming psychological distance [9] and are expected to have a positive influence on employees' ability to adjust to remote work [36]. Feelings of trust, for instance, may give remote employees greater confidence in their role within the work group or organization and facilitate further adjustment [37]. Interpersonal trust can be defined as the willingness to accept vulnerability and a positive expectation of others' trustworthiness [38]. It has been shown to have a positive effect on workplace cooperation [39], knowledge sharing [40], and organizational commitment [41]. Trusting relations between employees [42] and employees' trust in supervisors [43] enhance organizational change and can therefore affect how employees adjust to remote work. Trust also lowers the need for both employees and their supervisors to monitor and verify each other's work in the virtual context [44] and is crucial to the effectiveness of virtual workers [45]. Thus, we hypothesize the following: Hypothesis 3 . Interpersonal trust is positively associated with employees' adjustment to remote work. --- Social Isolation Social isolation is related to physical and psychological distance between coworkers. Isolation can be defined as the perception of a lack of availability of support and recognition, missed opportunities for informal interactions with coworkers, and not being part of the group [35]. In other words, isolation is a state of mind or a belief that one is out of touch with others in the workplace; as such, the desire to feel socially connected is thwarted [46]. In a remote work setting, perceptions of social isolation may be exacerbated, even though it is proposed that isolation is created mainly due to the lack of availability and not just spatial distance [35]. Perceived isolation has been identified as a potential obstacle for effectiveness among remote employees [47] and may reduce job satisfaction [46]. Hence, we hypothesize the following: Hypothesis 4 . Social isolation is negatively associated with employees' adjustment to remote work. --- Contextual Factors We extend previous models [9] of adjustment by explicitly considering the COVID-19 context within which adjustments are required. Specifically, we suggest that the severity of the change in work location-here, the discrepancy between earlier remote work experience and current remote work frequency-and the extent of broader disruptions of work routines triggered by the COVID-19 crisis impact on employees' adjustment to the "new normal" [5,48]. --- Change in Work Location The sudden requirement to work from home has led most employees to increase the frequency with which they work from home. For some, these changes are more substantial because they either did not engage in remote work practices or did so to a very limited extent prior to the COVID-19 outbreak. In contrast, for employees who are more familiar with these work practices either because they frequently work remotely or are used to working with dispersed colleagues, these new work realities may require less adjustment. Limited connections and access in remote locations seem to be the main challenges of virtual working spaces despite recent technological advances. We examine the role of changes in work location as the discrepancy between current remote work practices and remote work practices before the COVID-19 crisis. Transitioning to a remote work location may require adjustment to the working environment, including physical, technological, and social conditions of work [16]. The intuitive hypothesis here is that larger differences indicate more substantial changes in where work is conducted, which in turn could complicate adjustment. --- Hypothesis 5 . Changes in work location are negatively associated with employees' adjustment to remote work. --- Disruption of Work Routines Unlearning refers to the "breakdown of routines, habits, and cognitive frameworks" [49] . We use the term disruption to refer to an unlearning process in which routines, habits, norms, and procedures are changing [50] as a result of the COVID-19 pandemic. The adjustment required by employees depends on the level of disruption experienced by employees: greater disruption requires greater adjustment. Prior research demonstrates that environmental turbulence causes organizations and their subunits to face performance gaps, work stress, toxic work environments, and blame shifting as well as anxiety and fears [50]. Hence, we hypothesize the following: Hypothesis 6 . Disruption of work routines is negatively associated with employees' adjustment to remote work. --- Moderating Factors In addition to structural, relational, and contextual factors, remote work is structured and shaped by communication technologies that enable employees to interact across temporal and spatial boundaries. The quality of organizational communication and the frequency of CTU in times of changing work environments and dispersed work may prove to be of particular importance for employees to adjust to new work conditions. Organizational communication quality is defined here as the informativeness, accuracy, and timeliness of communication about organizational changes during the pandemic [51]. --- Organizational Communication Quality and Relational and Contextual Factors Communication has been found to mitigate the relationship between geographical distribution and conflict [52]. Although not directly related to adjustment, these findings imply that communication might have a positive impact on conflict identification and conflict handling, and as such may optimize remote work effectiveness and satisfaction, which are key indicators of adjustment. In addition, high-quality organizational communication can be viewed as a sign of organizational support that may help employees refocus on collective goals [53] to meet their performance expectations. In the absence of a traditional office environment, the role of organizational communication may be even more profound because it may substitute in part for a lack of face-to-face interaction while facilitating the information purposes of social support networks that are normally present in organizations [54]. Finally, communication tends to clarify role expectations and enhance performance by reducing uncertainty [51]. Therefore, we ask the following question: RQ1: Does organizational communication quality moderate the impact of structural, relational, and contextual factors underlying adjustment? --- Communication Technology Use and Relational and Contextual Factors Communication technologies are the enabling force behind most remote work settings, allowing workers to maintain necessary levels of connectivity to share information and coordinate work across various boundaries [55,56]. In addition, the effective use of communication technology is an important facilitator of trust in virtual teams [17,57,58]. Indeed, many organizations can be argued to have adopted some degree of virtual practices under the studied conditions, and collaboration strongly depends on the effective use of communication technology. ter Hoeven and van Zoonen [59] demonstrated that control over CTU reduces the negative consequences of spatial distance in remote work arrangements for helping behavior. Because CTU may amplify the positive association of relational factors with adjustment while mitigating the negative impact of other relational factors , we pose the following research question: RQ2: Does CTU moderate the impact of relational and contextual factors underlying adjustment? --- Materials and Methods This cross-sectional study targeted employees who had been asked to work remotely in Finland since the lockdown began in mid-March 2020. The survey started on the 26th of March 2020 and was open for responses until the 13th of April 2020. Open survey invitations were published online, and we solicited the help of several large labor unions and ministries to distribute the survey link to their members. The survey included about 100 items in total, including background questions and attention checks. The survey was administered through the XM platform Qualtrics and programmed such that all statements needed to be answered for the survey to be completed and responses to be considered for analysis. Explicit informed consent was obtained from all participants prior to the survey. Data were exported to IBM statistical software packages SPSS and AMOS for further analysis. There were no missing values as we used forced response options, respondents who failed the attention checks or dropped out were automatically excluded. Embedded data and identifying information were assessed to guard against duplicate responses, but were not used in the analysis stage. This convenience sampling procedure resulted in a total response of 5452 Finnish employees. Employees in our sample indicated low probabilities of job loss in the near future, with 84.4% indicating that this was improbable . The average age of the respondents was 45.3 years old . Most respondents were female , and 1593 were male . Most respondents were employed by the state or public utility , while 1318 respondents worked for private enterprises , and others worked in nongovernmental or semigovernmental organizations. The respondents mostly worked in organizations with 50 to 249 employees , 250 to 999 employees , or more than 2000 employees . The majority of respondents worked remotely 4 or more days per week , 6.5% worked remotely 2 or 3 days, and 2.6% worked remotely 1 day per week or less. Furthermore, respondents indicated they worked 38.6 h per week on average , and the average reported overtime was 2.3 h per week . Approximately 14% of the respondents worked in a managerial position, their average organizational tenure was 10.9 years , most respondents were part of single or two-person households, and 40% had at least 1 child under the age of 18 in their household. --- Measures All statements were measured using seven-point response scales ranging from strongly disagree to strongly agree unless indicated otherwise. All survey items were derived from earlier studies and reviewed by the research team, but we did not conduct a pilot study. Table 1 lists all measurement items, including descriptive statistics and factor loadings. --- Dependent Variable Adjustment to remote work was measured with a five-item scale assessing satisfaction with remote work, perceived performance as the consequence of remote work, and ability to balance work and non-work demands. The measure was adopted from Raghuram et al. [9], who used it in the context of virtual work. Adjustment refers to an overall state of adaptation because a transition to remote work highlights the inherent tradeoffs involved in adjustment [9]. For instance, research by [9] indicated that expending greater efforts to increase productivity may come at the expense of greater work/nonwork balance. Hence, an overall measure of adjustment may most accurately assess employees' relative level of adaptation to environmental demands. --- Structural Factors Independence was measured using four items adopted from [60]. Similar to Raghuram et al. [9], respondents were asked to indicate the degree to which their performance was dependent on working with others. Clarity of job criteria was measured using four items adopted from [61]. The items deal with handling problems on the job, figuring out what should be done to accomplish one's work, and being sure of how the job needs to be done. Items are based on role conflict and role ambiguity scales proposed by House and colleagues [62]. --- Relational Factors Interpersonal trust was measured using four items based on [61] adopted from [9]. In line with earlier research [9], our measurement strategy focused on an overall measure of trust rather than assessing the many specific determinants of trust. Two items relate how much the individual trusts his/her supervisor and colleagues, and two items measure the extent to which the respondent perceives that his/her supervisor and colleagues trust the individual. Social isolation was measured using three items derived from [35]. Social isolation measures the extent to which employees feel isolated and separated from others in the workplace. --- Contextual Factors Change of work location was measured by calculating the difference between remote work before the pandemic and current remote work frequency. Respondents were asked about the frequency with which they normally worked remotely, ranging from 1 to 7 . Subsequently, we asked respondents to indicate the frequency with which they worked remotely since the moment their organization took measures related to the COVID-19 crisis. By subtracting the scores, we calculated a difference score such that a higher value indicates a larger discrepancy in remote work practices compared with normal circumstances. Perceived disruption was measured by adopting eight items from [50,63]. The items address changes in work routines. Since routines are reflected in operating procedures during the performance of work, changes in plans, deadlines, and information-sharing mechanisms are indicative of an overall disruption of work. We asked employees to indicate the extent to which several activities, including project plans and deadlines, have changed since the organization took measures related to the COVID-19 crisis. --- Moderators Organizational communication quality was measured using six items from Bordia et al. [64]. These items have previously been applied in the context of uncertainty during organizational change. Quality of communication was measured using items such as "the communication my organization provided adequately answered my questions about the changes." Communication technology use was measured by asking respondents to indicate the frequency with which they used various technologies to communicate with their colleagues. The communication technologies we inquired about were email, telephone, instant messaging , online meetings , collaborative tools , enterprise social media , and public social media . Responses ranged from 1 to 7 . The items were computed to indicate an overall score for the frequency of CTU, with higher scores indicating more frequent communication with colleagues through these technologies. --- Results --- Measurement Model A confirmatory factor analysis was used to examine the hypothesized factor structure and investigate the validity of our measurement model. Subsequently, we examined common method variance using a common latent factor approach. The model demonstrated good model fit: χ 2 = 4432.49; CFI = 0.96; TLI = 0.95; SRMR = 0.04; PClose 1.000; and RMSEA = 0.039 . Following recommendations and threshold values reported by Hair et al. [65], the model demonstrated convergent and discriminant validity of the measures in our model . The average variance extracted ranged between 0.43 and 0.71. Discriminant validity was examined through the maximum shared variance , which ranged between 0.07 and 0.37 for the constructs in our model and is smaller than the AVE values. Additionally, the square root of the AVE was greater than the inter-construct correlations. Inspection of the model parameters indicated the absence of cross-loadings, overall suggesting good discriminant validity. Reliability was examined through the composite reliabilities and the maximum reliability , which ranged between 0.75 and 0.93 and between 0.77 and 0.93, respectively. Second, we examined common method variance using a common latent factor approach. Squared regression estimates indicated that common method variance was 3.6%, indicating that common method variance is not a substantial concern in our data. Curve estimations for all relationships in our model indicated that these relationships were sufficiently linear. Finally, the correlation between interpersonal trust and communication quality was relatively high . Hence, we inspected collinearity statistics for all independent variables and discovered no problems with multicollinearity. In sum, these results justify further inspection of the structural model. --- Controls We considered several potentially confounding factors in our analysis. Specifically, we controlled for gender, age, working hours per week, managerial position, organizational tenure, and job security. Gender significantly predicted adjustment , suggesting that female respondents were better able to adjust to remote work. Gender did not affect any of the hypothesized relationships in the model. Age did not affect adjustment to remote work . Similarly, the number of work hours per week did not significantly affect adjustment to remote work . However, the results indicated that managerial positions had a significant and negative relationship with adjustment , suggesting that individuals in managerial positions seem to have more difficulties adjusting to remote work. Finally, organizational tenure and job security did not affect adjustment to remote work or any of the relationships in our model. In sum, all hypothesized relationships remained unaffected when these variables were included. Hence, these variables were excluded from the final model for reasons of parsimony. --- Hypotheses Testing The hypothesized model was examined using path modeling in AMOS by estimating regression coefficients between the structural, relational, and contextual factors on adjustment to work. Table 3 provides the standardized and unstandardized regression results for the full model. Structural factors. Hypothesis 1 assumes that work independence is positively related to adjustment to remote work. The results demonstrate a significant positive relationship , p = 0.001). Hence, hypothesis 1 is supported. In addition, hypothesis 2 reflects the assumption that clarity of job criteria makes it easier for employees to adapt to remote work. The findings demonstrate a significant positive relationship between the clarity of job criteria and adjustment to remote work , p = 0.001). Hence, hypothesis 2 is also supported. Overall, these results provide strong support that the structural factors of an employee's job have an important influence on the employee's adjustment to remote work. Relational factors. Hypothesis 3 posits that interpersonal trust is positively related to employees' adjustment to remote work. The results demonstrate a significant negative relationship between trust and adjustment , p = 0.006). Hence, contrary to our expectations, trust between coworkers and supervisors does not increase adjustment to remote work but rather decreases it. A possible explanation could be that employees who exhibit lower levels of trust in their peers and supervisors rather work remotely, as this gives them more autonomy from people they do not trust and, therefore, they are less frequently confronted with such relationships. However, as the relationship is in the opposite direction than the one we hypothesized, we do not find support for hypothesis 3. Hypothesis 4 suggests that social isolation is negatively related to adjustment to remote work. The results demonstrate a significant negative relationship between perceived social isolation and adjustment to remote work , p = 0.001), providing support for Hypothesis 4. Contextual factors. Hypothesis 5 reflects the rationale that the relative change in work locations influences employees' adjustment to remote work. The results show that a change in work location is negatively related to adjustment to remote work , p = 0.001). This result suggests that a larger change in work location reduces employees' adjustment to remote work. Hence, hypothesis 5 is supported. This implies that employees who were already used to working remotely before the pandemic adjusted better to the new situation. Hypothesis 6 suggests that perceived disruption is negatively related to adjustment to remote work. The findings demonstrate a significant negative relationship , p = 0.001), providing support for hypothesis 6. The more work practices changed during the pandemic, the less employees were able to adjust. --- Moderations Before discussing the interactions, it should be noted that both moderators, organizational communication quality and the frequency of CTU , are significantly and positively related to adjustment. Note that all variables that comprise product terms were mean centered prior to testing the interactions. For all interactions, we inspected the values of the interactions effect at different values of the moderator using the Johnson-Neyman technique. When the interaction reported was not significant at all values of the moderator, we reported the value of the moderator at which the interaction becomes significant. To facilitate interpretation, the mean-centered values are also reported as actual values. Organizational communication quality. There was no significant interaction effect between organizational communication quality and trust , p = 0.995), social isolation , p = 0.149), and disruption , p = 0.722) on employees' adjustment to remote work. There was a significant interaction between organizational communication quality and change in work location , p = 0.001) on adjustment to remote work. This result suggests that at low levels of organizational communication quality starting at -4.11 , perceived change in work location negatively impacts adjustment to remote work. Organizational communication quality has a limited impact in mitigating this negative relationship. Finally, we did not find significant interactions between organizational communication quality and clarity of job criteria on adjustment , p = 0.620), nor did we find an interaction between communication quality and job independence on adjustment , p = 0.263). Communication technology use. There were no significant interactions between social isolation and CTU , p = 0.149). CTU was found to moderate the negative relationship between trust and adjustment to remote work , p = 0.002). The result indicates that trust negatively affects adjustment to work when the mean-centered value of CTU is below 0.562 . This suggests that when CTU is low, trust stifles adjustment to remote work, but when CTU is high , there is no significant negative effect of trust on adjustment to remote work. Arguably, frequent CTU is important when trust is low, to mitigate a decline in employees' commitment, satisfaction, and productivity. However, CTU is also important for adjustment when trust is high as a lack of communication may be more detrimental to adjustment in high-trusting environments. For instance, trust may be an indicator of high-quality relationships, missing out on such relationships in remote work settings may be detrimental to several aspects of adjustment, increasing the frequency of CTU to communicate and collaborate with trusted peers and supervisors might reduce the negative impact on employees' adjustment. In addition, CTU was found to moderate the negative relationship between change in work location and adjustment , p = 0.045). The findings suggest that change is negatively related to adjustment at all levels of CTU. However, smaller levels of change and a higher frequency of CTU yield the highest levels of adjustment. At one standard deviation below the mean of change, adjustment is higher when CTU is one standard deviation above the mean rather than below the mean , in which case adjustment is 5.07. Finally, CTU moderates the relationship between disruption and adjustment to remote work , p = 0.006). The confidence interval of the slope indicates that disruption has a negative impact on adjustment to remote work at all levels of CTU. However, it should be noted that higher frequencies of CTU allow employees to adjust better to remote work when disruption is high than when the frequency of CTU in these situations is low. --- Discussion The findings of this cross-sectional study during the early phase of the COVID-19 outbreak in 2020 in Finland indicate that structural factors make it easier for employees to adjust to remote work settings. In turn, relational factors are negatively related to adjustment. Contrary to our expectations and to the earlier findings by [9], interpersonal trust was negatively associated with adjustment to remote work. Arguably, trust serves as a proxy for important interpersonal functions, such as socialization and support; when such cues are missing, employees may feel less satisfied and effective and may therefore experience lower levels of adjustment to remote work. Our findings also show that feelings of social isolation decrease adjustment to remote work, providing further evidence that the social dynamics of work present a key barrier in adjustment during the COVID-19 pandemic. Furthermore, the results indicate that greater discrepancy between the amount of current and "normal" remote work and greater disruption in work practices both decrease adjustment. These results imply that beyond smaller changes in work location, greater experience with remote work seems to enhance adjustment to remote work. Finally, the findings demonstrate a relatively small positive impact of organizational communication quality and CTU in adapting to increased remote work. Organizational communication quality does not mitigate the negative impacts of relational factors on adjustment or facilitate the relationship between disruption of work practices and adjustment. However, more frequent use of various communication technologies with colleagues seems to mitigate the negative relationship between trust and adjustment, probably by reviving social relations. More research is needed to study the potential buffering effects of communication technology use and remote work adjustment. --- Theoretical Implications The findings have several theoretical implications. First, based on the theory of work adjustment [12] and the interactional model of individual adjustment [13], this study identified several crisis-specific environmental factors [6] in addition to "traditional" environmental factors proposed by [9] that may underlie employees' adjustment to remote work. For instance, we demonstrated that isolation is a relevant predictor that could be conceptualized as a relational factor underlying adjustment. In addition, we conceptualized contextual factors that include crisis-specific indicators such as changes in work location and perceived disruptions that impact adjustment. Finally, this study further considered how communication quality and CTU may mitigate some of the challenges in adapting to remote work. Ultimately, the study contributes to the literature on adjustment by identifying how employees' ability to adjust to abrupt transitions to remote work has been affected by various relevant factors of the work environment. Specifically, this study contributes to person-environment theories and the theory of work adjustment by identifying how the work environment may enable or constrain employees' ability to adapt. In other words, the work environment has reinforcement capabilities that can satisfy a person's needs [12]. Second, work independence and clarity of job criteria were positively and significantly related to work adjustment. This suggests that employees who know what is expected from them and can complete their tasks without others adjust better to working remotely. Hence, with regard to the structural factors underlying remote work, we were able to replicate the findings presented by [9] in the context of virtual work and add that these factors operate in similar ways across organizational settings during a global health pandemic characterized by abrupt lockdowns and en masse remote work directives. Furthermore, the findings align with [66], who find that telecommuters with higher autonomy report greater job satisfaction relative to those with less autonomy. Our findings are in line with previous literature linking performance management and goal-setting theory in co-located work settings. It has been established that specific goals can enhance motivation and performance by leading people to focus their attention on specific objectives [67], facilitate their attempts to achieve these objectives [68], persist in the face of setbacks [69], and invent new strategies to better deal with complex challenges related to goal attainment [70]. More broadly, the finding that work independence and clarity of job criteria are positively related to adjustment also signals a potentially important tension in remote work designs. While some level of independence and clarity at the individual level is desirable for job satisfaction, effectiveness, and performance in remote settings, modern work tasks require some level of interdependency, and employees may desire feedback, socialization and relatedness with peers. For example, in self-determination theory, relatedness is considered a basic human need that consists of interacting with, being connected to, and experiencing caring for others [31]. Recent studies on remote work [69] and global work [54] demonstrate the importance of considering both the job characteristics and the social characteristics of work. Research [54,55] indicates that as workers are afforded more autonomy and work becomes more unpredictable and volatile, employees need to adapt to contend with the demands of their work environment, including relational demands. This means that employees are active agents crafting their own jobs rather than passive recipients of work characteristics. This perspective aligns well with the findings of this study, which refer to agentic processes-here, independence and clarity, which empower employees to meet the demands of remote work and to adjust. Third, with regard to the relational factors, our findings do not support the hypothesis of a positive relationship between interpersonal trust and adjustment to remote work. The negative relationship between trust and remote work adjustment is a counterintuitive finding that contradicts most of the past research on the relationship between trust and remote work [9,71]. The findings indicate that higher levels of interpersonal trust decrease individual's adjustment to remote work. Alternatively, the reverse is also true as employees who report low levels of trust seem to adjust better to remote work. This result can be understood from an "out of sight out of mind" perspective, suggesting that some employees may benefit from being separated from colleagues or supervisors they do not trust, or even distrust. Indeed, in the context of this pandemic, scholars have chronicled that the transition to remote work may have benefits for employees as they might be less exposed to toxic workplace relationships, or relieved from bullying colleagues [5]. Our findings align with such insights. In addition, trust among colleagues and in supervisors could be an indication of a valued interpersonal relationship. Having to miss such a relationship may reduce one's satisfaction with their job and make it more difficult to maintain productivity levels or overall job performance-all indicators of adjustment. Hence, employees who report high levels of trust in coworkers and supervisors and who feel trusted by them may be less satisfied with remote work, feel less effective, and feel less adjusted. Employees may even want to return to the office as soon as possible to reconnect with their colleagues because the gratification of social needs is arguably satisfied through recurring physical interactions with colleagues. Furthermore, trust built in the physical context may not have transferred to the technology-mediated interactions of remote work environments yet, and if the respondents see limited opportunities to do so, this could lead to a less gratifying remote work experience. Finally, the notion that greater disruption requires greater adaptation certainly rings true for most individuals. The findings suggest that employees who experience greater disruption appear to face more difficulties adjusting to the work setting. Hence, it seems that disruption may indeed require adaptation, but the negative relationship suggests that employees have difficulty making the required adjustments, arguably because adaptation in these cases requires employees to learn new skills and competencies to deal with environmental demands. Hence, the findings demonstrate that employees' adjustment to abrupt remote work transitions is complicated by the perceived "strength" of the disruption. Overall, the findings suggest that factors underlying agentic processes facilitate adaptation and the reappraisal of event outcomes, while relational factors-trust and isolation-operate as barriers to adjustment. This phenomenon calls for further research into the managerial and sociopsychological processes that help to understand the relationship between disruptive events and organizational outcomes. --- Practical and Managerial Implication This study investigated the antecedents of adjustment to remote work. Some factors are directly within the scope of organizational control , while others may be more difficult to influence directly . However, the results provide important and actionable implications for organizations. First, our results indicate that employees who report higher levels of independence and clarity of job instructions are better able to adjust to remote work. In these circumstances, organizations could provide clearer objectives and goals and minimize interdependencies between organizational members by designing and allocating autonomous jobs and tasks where possible. In doing so, organizations facilitate agentic processes of individual employees, improving their adjustment to these settings. In addition, organizations need to ensure that there are adequate resources for employees to conduct work independently while maintaining interdependencies at the collective level. For instance, our findings show that CTU in particular, as well as organizational communication quality, may bolster adjustment to remote work. Managing relational factors deserves slightly more thought because higher levels of trust reduce adjustment, but isolation also reduces adjustment. Social isolation can be reduced in various ways, such as through synchronous video meetings and informal communication. For example, virtual coffee breaks may help employees feel connected to their coworkers and may lead to less isolation in the workplace. In addition, these initiatives might be important in the context of trust. We found a negative relationship with adjustment; however, we argue that trust in this case signals the absence of important interpersonal cues in the physical workplace. Hence, facilitating interpersonal mechanisms of socialization and support might mitigate the negative impact of trust on adjustment. Furthermore, to facilitate greater adjustment in times where resources could be particularly scarce and feelings of isolation particularly high, scholars have suggested that teleconsultations and informal online support groups could help people stay connected [72][73][74]. In addition, the findings demonstrate that greater change in work location and greater perceived disruption hamper adjustment to remote work. This is important because it signals that organizations and managers should be attentive, especially to employees whose work processes require the greatest adaptation. Our findings show that employees with more experience in remote work adapt to new situations better because they have already learned some practices and competencies needed in remote work. This implies the importance of training. Organizational support for work-home issues significantly improves well-being [75] and may aid adjustment. For instance, organizations may support their employees through lower workloads or other job demands, giving them greater opportunities to adjust. Additionally, for employees working on vital processes, organizations could have different approaches based on the extent to which the work routines of individuals or groups are disrupted. For instance, these workers could be given priority to use workplace facilities. --- Limitations and Future Research Several limitations need to be acknowledged. First, this study relies on cross-sectional survey data obtained through a convenience sampling method. This method presents two limitations. First, the data do not permit any causal inferences and do not permit us to track how changes in, for instance, perceived disruptions and continued adjustment to the work environment develop over time. Second, the sampling method resulted in a relatively homogeneous group of employees, limiting the generalizability of the findings. The nonrandom sampling technique as well as the sample and population information do not provide sufficient auxiliary information to correct survey responses using weight adjustments. The sample consisted predominantly of Finnish civil servants , many of whom engaged in what could best be described as knowledge work. In addition, we surveyed respondents who had the available means to participate in the study . Furthermore, the relatively stable work context of these employees and the Finnish socioeconomic system may be fertile ground for the adjustment of employees, which may not be the case in other types of occupations [5], other socioeconomic systems, or countries that were more strongly affected by the pandemic [6]. Future research is needed to demonstrate the generalizability of our findings across a broader range of occupations, countries, and socioeconomic systems. Second, some of the effect sizes are relatively small, which raises questions about the predictive validity of the model. To substantiate these findings, future research is needed to confirm these results over time with various occupational groups in different socioeconomic systems. In addition, although the measures were adopted from previous studies, not all measures have been validated and we do not have pre-pandemic benchmark indices for our population, limiting our ability to draw a conclusion about the relative changes. In addition, responses were collected within the first month of the outbreak. Although this timeframe is considered appropriate to investigate adjustment processes, these processes are also likely to continue as the pandemic evolved. In addition, people now have had more time to adjust and find ways to meet challenges and demands associated with teleworking. Hence, it would be worthwhile to follow up on this study as the relative newness of the pandemic and associated teleworking has decreased. Finally, our findings suggest that employees seem to adjust well to remote work. This aligns with studies that conclude that the general attitude toward working from home seems positive [76]. However, this study was conducted in the early stages of the pandemic; therefore, limited assumptions can be made about the long-term implications. In addition, future research may probe more deeply into different aspects that are central to adjustment to remote work, such as those related to work-life dynamics. For instance, now is the opportune time to study whether childless and single employees face increased expectations and work responsibilities, and how these demands may interfere with non-work demands [3]. --- Conclusions The findings presented in this study provide important insights into the factors that are consequential to employees' adjustment to remote work. These findings contribute to our understanding of how the COVID-19 pandemic has impacted work. This is important because the current crisis is far from over [74,77], future pandemics are increasingly likely [74], and other disruptive events, such as economic downturn, natural disasters, activism, and war, may require continuous adjustment from employees and organizations. Our findings contribute to an understanding of how employees adjust to changes in their work environment by identifying and demonstrating the interplay between various environmental and contextual factors. --- Data Availability Statement: The data presented in this study are not publicly available. Survey respondents were assured raw data would remain confidential and would not be shared. --- Author Contributions: Conceptualization, W.v.Z., A.S., K.B., T.O., A.R., K.H., and M.V.; methodology, W.v.Z.; software, W.v.Z.; validation W.v.Z.; formal analysis, W.v.Z.; investigation, W.v.Z.; resources, A.S. and K.B.; data curation, W.v.Z.; writing-original draft preparation, W.v.Z.; writing-review and editing, W.v.Z., A.S., K.B., T.O., A.R., K.H., and M.V.; supervision, K.B.; project administration, A.S. and K.B. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: Ethical review and approval were waived for this study, as the study did not involve any of the following: underage subjects, exposure to strong stimuli, potential for long-term mental distress, or intervention with the physical integrity of the participants. Informed Consent Statement: Informed consent was obtained from all participants involved prior to the study. ---

The COVID-19 crisis has disrupted when, where, and how employees work. Drawing on a sample of 5452 Finnish employees, this study explores the factors associated with employees' abrupt adjustment to remote work. Specifically, this study examines structural factors (i.e., work independence and the clarity of job criteria), relational factors (i.e., interpersonal trust and social isolation), contextual factors of work (i.e., change in work location and perceived disruption), and communication dynamics (i.e., organizational communication quality and communication technology use (CTU)) as mechanisms underlying adjustment to remote work. The findings demonstrate that structural and contextual factors are important predictors of adjustment and that these relationships are moderated by communication quality and CTU. Contrary to previous research, trust in peers and supervisors does not support adjustment to remote work. We discuss the implications of these findings for practice during and beyond times of crisis.

Introduction Individuals from marginalized populations in the United States are at elevated risk of poor health, disability, and premature death . Such health disparities are defined as adverse health outcomes for communities that have, as a result of "social, economic and environmental disadvantage, systematically experienced greater obstacles to health" . Although a primary objective of the NIH is to eliminate health disparities among marginalized groups , it was only in Healthy People 2020 that lesbian, gay, bisexual, and transgender people were for the first time identified in U.S. health priorities as an at-risk population . The Institute of Medicine has determined LGBT populations are health disparate and underserved, recognizing the lack of attention to sexual and gender identity as critical gaps in efforts to reduce overall health disparities . While health disparities research mainly documents group differences in health outcomes, a more propelling goal is to promote health equity, defined by Whitehead and Dahlgren as the opportunity to attain full health potential. Krieger et al. describe a health equity perspective as "the instrumental use of human rights concepts and methods for revealing and influencing government-mediated processes linking social determinants to health outcomes, especially in relation to the principles of participation, nondiscrimination, transparency, and accountability" . --- LGBT Health Disparities According to population-based surveys, about 3.5% of U.S. adults self-identify as lesbian, gay, and bisexual and 0.3% as transgender , which correspond to approximately 9 million people. These numbers increase dramatically when same-sex sexual attraction and behavior are also considered. Clearly, there is a sizable subgroup of Americans whose health merits increased research attention. Sexual and gender identity are complex constructs and are highly contingent upon culture and social context, which can shift rapidly over time. Sexuality encompasses at least three key components: sexual identity, sexual attraction, and sexual behavior. Sexual identity is an individual's own perception of his or her overall sexual self. For many people their sexual identity, such as lesbian, gay, bisexual, or heterosexual, is consistent with their sexual attraction and behaviors, but for some individuals sexual identity may be inconsistent with attraction and/or behavior. For example, a man whose primary sexual partner is a woman may identify as heterosexual yet occasionally have sex with men. Sexual identity may be more fluid than previously assumed, especially among women . Gender refers to the behavioral, cultural, or psychological traits that a society associates with male and female sex. Transgender generally refers to people whose gender identity is at odds with the gender they were assigned at birth according to their sex and physiological characteristics of their bodies. For example, a transgender woman is a person who was born physiologically male but whose deepest sense of self is as female. It is important not to conflate sexual and gender identity because they are separate constructs . With the inclusion of questions on sexual identity in an increasing number of national population-based health surveys, a growing body of research is documenting health disparities among LGB people. Specifically, LGB people are at higher risk for poor mental health , psychological distress , suicidal ideation , and mental health disorders compared with heterosexuals . More recent research is investigating the physical health of LGBT people. Relative to heterosexuals, LGB populations have higher rates of disability , more physical limitations , and poorer general health . Elevated rates of HIV are also observed among gay and bisexual men and transgender women . Among lesbian and bisexual women, there are higher rates of overweight and obesity . Although findings are mixed, some studies have indicated LGB adults may be at elevated risk of some cancers and cardiovascular disease . Large population-based studies have found that LGB adults are more likely to report diagnoses of asthma than their heterosexual counterparts . With few exceptions, limited research has focused specifically on the health status of transgender individuals. Two recent studies with large national samples of transgender individuals found that rates of depression, anxiety, and overall psychological distress were disproportionately higher for this population than for non-transgender women and men . Research findings also document disproportionate rates of military service , incarceration , sexual violence , and poor general health among transgender people. --- LGBT Historical Context Historically, homosexuality in the United States has been largely invisible, because it was often equated with deviancy, sickness, and shame. Same-sex sexual behavior was against the law, with sodomy a criminal offense in all 50 states prior to 1961 . Until its removal from the Diagnostic and Statistical Manual of Mental Disorders in 1973 , homosexuality was treated as a "sociopathic personality disorder." Both prejudice and stigma likely result in higher rates of mental health problems among LGBT people , which is reflective of the historical practice of pathologizing and criminalizing LGBT people. Despite the larger social stigma, underground communities accessible to sexual minorities began to develop in major metropolitan areas during and after World War II . In 1969 after a routine police raid on an LGBT night club in New York City, the Stonewall Riots erupted as an act of resistance, sparking the modern U.S. gay rights movement. Despite the progress, a growing backlash from conservative and religious elements in society combined with AIDS-related losses in the early 80s and into the mid-90s, shifted the dominant discourse of homosexuality to a sin punishable by death . Yet, this too was actively resisted by LGBT activists and grassroots political organizations shifting from resistance to a growing urgency for "emancipation" . More recently, the marriage equality debate has shifted dramatically since the federal prohibition of same-sex marriage through the Defense of Marriage Act. LGBT people can now legally marry in more than 30 states and Washington, DC, and lawsuits regarding marriage equality are pending in all other states, as well as the Commonwealth of Puerto Rico . Yet, still today, discrimination in employment, housing, and public accommodations is not prohibited on the basis of sexual orientation or gender identity by federal law . In 2013, while the DSM-5 reclassified "gender identity disorder" as "gender dysphoria," which is no longer pathological per se, the classification continues to stigmatize transgender people via a "mental disorder" classification that is dependent on "clinically significant distress or impairment" . --- Risk Factors for LGBT Health Disparities While biological and genetic influences on health in the general population receive ample attention , much less is known about the effects of structural and environmental contexts on health and the roles of social determinants, which may vary considerably across marginalized groups. Indeed, the World Health Organization has affirmed that "the root causes of health inequities are to be found in the social, economic, and political mechanisms" . Yet, only a handful of studies have examined the effect of discrimination and social stigma on physical as well as mental health outcomes in LGBT populations . In conceptualizing the determinants of LGBT health disparities, researchers have relied almost exclusively on stress and coping models. The Stress Process Model first addressed the influence of stressful life events associated with structural inequalities on mental health. According to the model, disadvantaged status, traumatic early events, and unexpected life transitions in one's social role, behaviors, and social relationships cause both long-term stressors and proliferated stressors, which, in turn, impact health and well-being. Most notably, the Minority Stress Model postulates that sexual minorities experience increased mental health problems because of stress processes unique to their status, namely discrimination, expectations of rejection, concealment, and internalized homophobia. Hatzenbuehler expanded upon this model with the Psychological Mediation Framework, which suggests that emotion dysregulation, interpersonal problems, and cognitive processes mediate the link between heightened stressors because of sexual minority status and psychopathology. While these theories advance our understanding of LGBT mental health disparities, current conceptualizations fail to explain why many LGBT people enjoy good health despite adversity and to articulate the multilevel factors that may influence the continuum of LGBT health over the life course. --- Reconceptualization of LGBT Disparities: The Health Equity Promotion --- Model We propose a new conceptual framework that situates LGBT health across the life course and focuses on how minority status related to sexual and gender identity can result in variations in health for LGBT populations over time. Examining the resilience as well as risks that influence LGBT people is a first step toward a comprehensive understanding of their health across the life course. Resilience factors that may delink the relationship between stressors in early life and consequential health deterioration in later life have not been adequately addressed in previous frameworks. Based on a conception of health equity, a primary premise of this framework is that all individuals have a right to good health, and it is a collective responsibility to ensure all obtain their full health potential. Highlighting the importance of intersecting social positions within a life course perspective, the framework acknowledges both inter-and intragroup variability, and that an individual's development of health potential can vary within a group of individuals who share a similar life course . The framework points to structural and environmental factors as determinants of health as well as community and individual-level factors, highlighting resources, resilience, human agency, and risks. A life course perspective provides a means for taking into consideration both historical and social contexts that are shared by age cohorts and the unique needs, adaptation, and resilience of LGBT individuals as human agency. This perspective highlights differences in experience between an LGBT person who came of age when homosexuality was considered a psychiatric disorder compared with an LGBT adult now in early adulthood during the marriage equality debates. Equally important, a life course perspective identifies an individual life trajectory as important in understanding current health outcomes . The Health Equity Promotion Model considers the ways in which both the exclusion and resistance of LGBT people has played out over time given the shifting historical and social context. According to Elder , "Individuals construct their own life course through the choices and actions they take within the opportunities and constraints of history and social circumstances." For example, despite historical and social marginalization, LGBT individuals have developed their own ways of building communities and behavioral and psychological coping skills . The Health Equity Promotion Model, building upon the Minority Stress Theory and the Psychological Mediation Framework, integrates a life course development perspective within a health equity framework to highlight how social positions and individual and structural and environmental context intersect with health-promoting and adverse pathways to influence the continuum of health outcomes in LGBT communities . While not intended as a theory or exhaustive classification of the determinants of LGBT health, the framework provides a guide to consider the multiple levels and intersecting influences on the full continuum of LGBT health, especially as they relate to equity and resilience in LGBT communities. It aims to stimulate research that addresses the full component of factors influencing the range of LGBT health outcomes. --- Social Positions As health occurs within a social context , it is not surprising that marginalized social statuses are linked to disparities in health outcomes . A consideration of social positions and health must include attention to the complex nature of intersecting social positions including diverse sexual and gender identities and how social locations interact and the potential for synergistic disadvantage or advantage based on multiple statuses . Yet, most health research has ignored heterogeneity within LGBT communities , without exploring how LGBT health is differentiated by social position . As Figure 1 demonstrates, combinations of these social positions may be associated with types of marginalization-as well as potential for strength, resilience and opportunities. We do know that there are sex differences in LGBT health behaviors , social networks , and health outcomes . Gender expression appears to be another important factor to consider, as one's level of femininity or masculinity has been found to be associated with different types of stressors . Both transgender and bisexual people experience systemic disparities and emerge as critically underserved and at-risk populations, who also display important strengths . For example, evidence has documented pronounced socioeconomic risks and health disparities among transgender people , yet they also have larger social networks as compared with LGB people . Such sexual minority social positions can be sources of strength for LGBT people, such as providing a "family of choice," community support, and pride in one's identity and community . Less is known about the health of LGBT persons of color. As described in the Health Equity Promotion Model, race and ethnicity and culture intersect with sexual and gender identities. For example, studies find differential response rates to sexual orientation questions by race and ethnicity . Although the term LGBT is most often used, research has found that Asian Americans often identify their sexual orientation as "queer" , and African Americans often use the term "same-gender loving" , both of which are most often treated as missing in research studies. Furthermore, some commonly used sexuality terms related to sexual identity are not translatable in Spanish . A potent example of the intersection of culture, race, and sexual and gender identities is the experience of two-spirits. According to Walters and colleagues: "The term two-spirit is used currently to reconnect with Native American and tribal traditions related to sexual and gender identity; to transcend the Eurocentric binary categorizations of homosexual versus heterosexual or male versus female; to signal the fluidity and nonlinearity of identity processes; and, to counteract heterosexism in Native communities and racism in LGBT communities" . --- Multilevel Context: Individual Manifestations, Such As Microaggressions, Discrimination, and Victimization; and, Structural and Environmental, Such --- As Societal and Institutional Levels of Oppression and Social Exclusion Microaggressions and interpersonal assaults and overt acts of discrimination may have a significant impact on LGBT individuals' health. Characterized as enacted stigma, such acts have been defined as "the overt behavioral expression of sexual stigma through actions such as the use of antigay epithets, shunning and ostracism of sexual minority individuals, and overt discrimination and violence" . The Minority Stress Model specifically addresses the negative influence of such social stressors on mental health among LGBT individuals. In addition, recent studies also found that discrimination is associated with physical health outcomes among gay and bisexual men . Discrimination and victimization has been found to be associated with disability, depression, and poor general health . LGBT people who have been physically assaulted report more loneliness, poorer mental health, and more lifetime suicide attempts . Among transgender older adults, lifetime victimization explains heightened risks of poor health outcomes . Injustice in health is also exercised at the societal and institutional level. Hatzenbuehler and his colleagues argue that although societal conditions and social norms can systematically and institutionally disadvantage marginalized individuals and lead to poorer health outcomes, little research has examined to what extent such social exclusion influences physical health. Structural and contextual factors create a context of marginalization and oppression, including laws and policies that unfairly treat sexual and gender minorities as well as cultural and institutional oppressions, widespread societal stigma, and religious intolerance and persecution. For example, population-based data indicate that most Americans have access to health care, yet evidence suggests that LGBT adults may have less access to health care when needed . In one of the largest surveys of transgender individuals, participants indicated high levels of postponing medical care when sick or injured, as well as significant barriers to accessing health care . In addition, differences in geographical contexts may impact health for LGBT populations. For example, a study found that nonurban dwelling lesbians are less likely than urban-dwelling lesbians to disclose their sexual identity to health care providers . Social inclusion also positively impacts the health of LGBT adults. Population-based longitudinal data offer support that legally recognized marriage, for example, bestows benefits for health and longevity for both men and women in the general population . The American Medical Association acknowledges that lack of access to the benefits of full marriage equality contributes to health disparities among LGB adults. Living in states that specifically ban same-sex marriage is linked to increases in mood disorders . Research suggests that same-sex couples in legally recognized relationships experience less psychological distress and lower levels of internalized heterosexism and better health than their counterparts in committed but not legally recognized relationships. --- Health-Promoting and Adverse Pathways, Including Behavioral, Social, Psychological, and Biological Mechanisms As Figure 1 indicates, these four mechanisms mediate the effects of individual and structural and environmental context on health outcomes; equally importantly, the four mechanisms can moderate these relationships, which account for how health trajectories may differ among LGBT individuals who share similar life experiences. In other words, despite the stressful experiences of discrimination and social exclusion, some LGBT individuals maintain health potential by utilizing health-promoting resources that they have cultivated through life. As discussed below, the proposed model suggests that the four pathways offer both health-promoting and adverse mechanisms. As behavioral pathways, both health-promoting and adverse health behaviors are observable human acts, by an individual or group of individuals, to change or maintain health. Adverse health behaviors that are linked to poor health as well as the action of individuals in the promotion of good health and prevention of illness are important components of the proposed model. LGBT adults report disproportionately higher levels of some adverse health behaviors including higher rates of smoking , excessive drinking , and in some cases drug use , which are leading causes of preventative deaths. Studies found that experiences of discrimination are associated with elevated use of substances among LGBT individuals . In terms of health screenings, lesbian and bisexual women may be at risk of not utilizing preventive health care and screenings although findings are mixed . Studies found that lesbians with higher levels of perceived health care discrimination are more likely to delay utilizing cervical cancer screening . Moreover, transgender individuals report high levels of postponing medical care, often because of fears of discrimination or inability to afford care . How behavioral pathways operate, and their interaction with social and historical marginalization as well as community norms and expectations among LGBT populations, remains unanswered. Obesity is one example. The rates of obesity in the United States have steadily increased in recent decades , and studies suggest that chronic discrimination may be associated with elevated risk of obesity . Yet, despite experiencing greater discrimination, gay men are less likely than heterosexual men to be overweight or obese , and they are more likely to diet, be fearful of becoming fat, and feel more dissatisfied with their bodies . Lesbians, on the other hand, are more likely than heterosexual women to be obese . In a study matching lesbian and heterosexual sisters, lesbians had greater waist circumferences, waist-to-hip ratios, higher body-mass indices, and more extensive weight-cycling . Nonetheless, they are more likely to exercise on a weekly basis. Indeed, in a study that examined health behaviors over the adult life course by sexual identity, lesbians under the age of 50 had increased odds of moderate activity, and bisexual women had increased odds of muscle strengthening relative to their heterosexual counterparts . Diet and exercise as well as weight management are critical determinants of morbidity and mortality and thus should be examined in LGBT populations to understand the complex ways in which these behaviors and community norms interact to impact health in both positive and negative ways. Social processes, which include the effects of interrelationships with others on health, have been widely documented . As Hatzenbuehler and colleagues proposed, discrimination and social exclusion lead to social isolation among LGBT individuals; but for those who have developed strong social resources through their life course, the negative impact of adverse experiences on health may be alleviated . Antonucci argues that social relations and networks are shaped through one's life course and differentiated by personal and social factors. In the general population, social network size and type influence health outcomes , yet social networks differ between LGBT people and the general population. LGBT people often develop "families of choice," extended networks of partners and friends , with less reliance on legal or biological family members. There is compelling evidence that social factors may increase social capital and that living in states that have higher concentrations of same-sex couples may be a protective factor for health . A large community-based sample of New York City LGB adults found that community connectedness and integration is significantly related to well-being, with bisexuals and young adults evidencing the lowest levels of integration into these communities . Interestingly, a recent study suggests that social network size among LGBT adults may not be related to positive physical health outcomes; more likely it is the quality and not the quantity of social contacts that is more important . In terms of psychological and cognitive processes, Hatzenbuehler's Psychological Mediation Framework identifies general and minority-specific psychological processes that mediate the link between stressors and psychological health. General psychological processes include positive processes such as problem solving and active coping, as well as negative processes such as rumination and avoidant coping. Minority-specific psychological processes, identified by Meyer , include internalized homophobia, expectations of rejection, and identity concealment. The negative impact of minority stressors such as discrimination and victimization on psychological processes has to be further investigated; a certain extent of exposure to stressors related to disadvantaged social positions over the life course may help to develop stress-coping capacity . Because most LGBT people are not readily identifiable to others as such, they manage the disclosure of their sexual and gender identity. Disclosure, which is in part dependent upon the degree to which a stigmatized identity has been integrated, increases opportunities to strengthen social relations and allows for association and interaction with other LGBT people . Whereas disclosure can expose an LGBT person to hostility from others , maintaining a positive sexual identity has been associated with positive health outcomes . Whereas biological influences on health in the general population are documented, they have seldom been investigated in LGBT research. Yet, some biological processes may be particularly relevant in LGBT populations given the larger social context and history of marginalization. For example, the biological stress process is applicable to the proposed framework. Physiological responses to chronic stressors are important predictors of health. For example, allostatic load , a physiological stressrelated mechanism linking the psychosocial environment to physiological dysregulations , is associated with cardiovascular disease, cancer, infection, cognitive decline, accelerated aging, and mortality . It is important to note that AL may be influenced by the other mechanisms in the proposed model. For example, positive behaviors, such as exercise, as well as adverse behaviors, such as smoking and excessive drinking, both influence, although in different directions, the physiological responses to chronic stressors. Still, such biological influences on both positive and negative health among LGBT individuals have not been adequately investigated, although a growing number of studies are assessing physiological responses to stressors among sexual minorities, especially among those living with HIV disease . --- Implications for Future LGBT Health Research, Policy, and Practice The specific framework used for understanding health outcomes influences the type and targets of interventions proposed. Grounded in the Health Equity Promotion Model, we make several recommendations for the field. --- Research Implications Previous LGBT health disparity studies have mainly utilized deficit-focused models to understand poor health outcomes, while existing research shows manifestations of resilience and good health among LGBT people . Investigating sexual and gender identity-specific strengths and resources are equally important in the effort to understand LGBT health. It is essential that efforts consider the health-promoting mechanisms, such as human agency and resistance of LGBT people, as we explore the opportunity to attain full health potential. As Krieger and colleagues asserted, to advance health, both human rights and the important roles of participation, nondiscrimination, transparency, and accountability must be considered. Research simultaneously needs to explore the myriad ways in which multiple forms of social exclusion and marginalization interact with behavioral, social and community, psychological, and biological factors at multiple levels to identify factors that foster or impede health equity. To this end, it is required that information regarding sexual and gender identity, behavior, and attraction be collected as is data on other sociodemographic characteristics that are known to influence health, including age, race, ethnicity, gender, income, education, and many others. Both bisexual and transgender people are found to be vulnerable to poor health and their distinct needs must be considered. Further research needs to also examine their adaptation and resilience in the face of social exclusion. Furthermore, research studies must incorporate LGBT individuals of varying social positions to examine the influence of the intersectionality of social positions on health. For example, the experiences of LGBT people of color and those of varying socioeconomic statuses are largely absent in existing research. Exploring potential effects of cumulative risks and resources over the life course across multiple social positions that can be simultaneously occupied by LGBT individuals will allow for a better understanding of the full range of health outcomes and resources and risks for the development of culturally responsive interventions. Multilevel methods that allow for analysis of structural/environmental contexts are necessary to fully understand LGBT health disparities. Current intervention efforts are often solely focused on the individual, such as d-up: Defend Yourself! for Black men who have sex with men to promote condom use for HIV/STI prevention ; smoking cessation for lesbian and bisexual women ; and support groups for LGBT youth to protect against suicide . In addition to these, targeting larger systems including policy or other environmental and structural change initiatives may better promote health equity and lead to improved health outcomes. To this end, longitudinal studies, currently sparse in LGBT research, are necessary. Understanding individual trajectories and cohort variations in health within shifting structural and environmental contexts would help to articulate ways to promote health equity. In addition, it is important to recognize the potential tension between heterogeneous approaches given the diverse nature of these communities and the need for system-level changes, which often assume more homogenous needs. For example, promoting calorie reduction may be helpful for weight control among sexual minority women but may be potentially harmful for sexual minority men if body image issues outweigh obesity concerns. Researchers must work to translate such findings into practice and use results to advocate for policy change. --- Policy Implications Several policy changes are needed to promote health equity, including nondiscrimination laws in employment, housing and public accommodations, marriage equality, and legislation to support non-kin caregivers. Sexual and gender identity need to be added as protected classes in an expansion of the 1964 Civil Rights Act. In 2012, the Equal Opportunity Employment Commission ruled that gender identity is protected under Title VII of the 1964 Civil Rights Act . Although federal agencies are increasingly ruling that sexual and gender identity fall under the prohibitions against discrimination based on sex and sex-stereotyping , the lack of uniform application makes enforcement challenging. Policies and politics play a significant role in promoting good health . Another important policy debate impacting the lives of people in same-sex relationships is recognition of same-sex unions, though not all LGBT individuals would choose or desire to be married. Most recently, the number of states in the United States that have legalized same-sex marriage continues to grow at a rapid rate. Legal marriage can provide access to significant economic benefits; for example, through Social Security, those married and who reside in states with legal same-sex marriage have access to spousal and survivors' benefits, that until recently were not available to same-sex couples. It is important to recognize that many of the current policy advocacy efforts are primarily addressing the needs of LGBT people in committed relationships. Yet, such policies do not adequately address the needs of LGBT people who are single, in nontraditional relationships, or partnered with no desire to become married. Thus, it is critical that families of choice and next-of-kin that are not partners or biological or legal family members are also considered in policy advocacy efforts. For example, extending paid leave laws to friends and other informal caregivers in alternative family structures is needed. Given that legal marriage may also result in divorce, it will be equally important to examine how these legal changes shift the nature of helping relationships and social resources in these communities, such as support provided by ex-partners and family of choice. --- Practice Implications Utilizing an equity perspective, focusing on resilience and human agency by capitalizing on the benefits of LGBT communities, can allow for social movement, akin to how the LGBT community united against HIV . For example, it is imperative to increase attention to health behaviors, both positive and adverse, and their role in health outcomes. Intervention research is needed that increases proactive preventive behaviors such as targeted screenings to reduce risk for MSM of color in terms of HIV/STIs and high rates of smoking in LGBT youth and adults . Also, utilizing community norms and behaviors, such as interventions for diet and weight control based on popular opinion leaders to endorse behavior change, may be an innovative way to take advantage of social capital. Life course perspectives, highlighting rapidly changing social norms related to both sexual and gender identity, raise important generational issues for future study. For example, will the lexicon used today, including the term "LGBT," remain stable or even useful given increasingly supportive views among the general population and the embracing by younger generations of diverse sexual and gender identities? To shift practice to promote health equity, practitioners will need to assess their own overt and covert biases regarding LGBT people, and understand how these, as well as the lives of LGBT people, have been and continue to be shaped by contested, shifting sociocultural and historical discourses . In addition, practitioners must use their practice knowledge and commitment to social justice to advocate for policy change and equitable access to services. Policymakers also need to understand the ways in which policies have and continue to shape the larger social context and access to resources within society. Empirically based information is needed to help shape the discourse relative to policy development and implementation so that policymakers can make the most informed, socially just decisions regarding the distribution of resources and their role in promoting health equity. Finally, adopting a health equity framework has global and human rights implications. A health equity perspective endorses social justice by highlighting the role of societal structures and human rights in health. Increasingly, international human rights agreements include rights to health care and endorse accountability for the health and health policies of nations . Achievement of health equity requires empowering LGBT people and their allies to take action and address the environmental and structural resources and risks that influence their health. --- Health Equity Promotion Model

National health initiatives emphasize the importance of eliminating health disparities among historically disadvantaged populations. Yet, few studies have examined the range of health outcomes among lesbian, gay, bisexual, and transgender (LGBT) people. To stimulate more inclusive research in the area, we present the Health Equity Promotion Model-a framework oriented toward LGBT people reaching their full mental and physical health potential that considers both positive and adverse health-related circumstances. The model highlights (a) heterogeneity and intersectionality within LGBT communities; (b) the influence of structural and environmental context; and (c) both health-promoting and adverse pathways that encompass behavioral, social, psychological, and biological processes. It also expands upon earlier conceptualizations of sexual minority health by integrating a life course development perspective within the health-promotion model. By explicating the important role of agency and resilience as

Introduction Myocardial infarction and cardiovascular disease are prominent global health issues, which also pose a major burden within the Somali population. The Somali population encounters distinct obstacles as a result of the repercussions of armed conflict, limited access to education, and an underdeveloped healthcare infrastructure. Myocardial Infarction , commonly known as a heart attack, is a critical medical condition characterized by the interruption of blood supply to a part of the heart muscle, leading to the death of heart tissue. It is a global health concern with significant variations in knowledge, attitude, and practices in different regions, including Africa and specifically Somalia. Numerous researches have shed light on the significant frequency of cardiovascular risk factors within Somali communities, encompassing conditions such as diabetes, hypertension, and obesity. 1 These identified risk variables are known to play a significant role in the pathogenesis of myocardial infarction and cardiovascular disease . Furthermore, it has been observed that Somali immigrants and refugees residing in the United States face an elevated susceptibility to obesity and associated cardiovascular health risks. 2 This observation indicates the necessity of implementing specific interventions aimed at addressing these risk factors and enhancing cardiovascular well-being within the Somali population. While there is limited research specifically focused on MI in Somalia, studies conducted in other African countries and among Somali diaspora populations provide valuable insights into the knowledge, attitudes, and practices regarding these conditions. Furthermore, the prevalence of MI is unknown in Somalia but is presumed to be high. The influence of socioeconomic factors on the development and management of cardiovascular illnesses is of paramount importance. Research undertaken in the sub-Saharan African region, encompassing adjacent nations such as Ethiopia and Tanzania, has shed light on the influence of low socioeconomic level on cardiovascular risk factors and outcomes. 3,4 Understanding and managing cardiovascular illnesses requires a high level of health literacy. For instance, low health literacy has been linked to an increased risk of death in people with end-stage renal disease. 5 Attitudes toward healthcare and preventative medicine also have an impact on the treatment of MI. Somali patients are less familiar with preventive healthcare practices and tend to seek medical attention only when they are sick. 6 Aside from individual knowledge, attitude, and practice, the healthcare system is also important in preventing myocardial infarction. The value of evidence-based preventative strategies is emphasized in guidelines for the management of acute myocardial infarction. 7 This study aims to analyze knowledge, attitudes, and behaviors about myocardial infarction among Mogadishu citizens, focusing on socio-economic issues and health literacy, to address healthcare obstacles and improve cardiovascular health outcomes within the Somali community. --- Methods and Materials Design and Settings A cross-sectional survey in the form of paper-based questionnaire was prepared for this study and used for data collection from 1 June to 31 August to examine Somalia inhabitants' Perceptions, Attitudes, and behaviors towards Myocardial Infarction. A random sample of participants who arrived at our hospital Mogadishu Somali Turkish Training and Research Hospital for various reasons were referred to our cardiology clinic for the study, they were greeted by a resident doctor, consent was obtained, and they were supported in understanding and answering the questions. --- --- Questionnaire The questionnaire utilized was similar to other myocardial infarction questionnaires. It was, however, specifically created for our demographic. The questionnaire was written in Somali, and the writing was clear and concise. The process of creating the questionnaire began with the establishment of precise research goals pertaining to cardiovascular health within the community. The selection of important variables was guided by a review of the literature. The questionnaire was created using language that was considerate of cultural differences and underwent validity testing. Any problems with the clarity and cultural appropriateness of the questions were found and fixed in a pilot study with a diverse sample. As a result, the questionnaire is revised. By giving the updated questionnaire to a subset of participants twice, test-retest reliability is guaranteed. The final version is then utilized to collect data for the primary sample. The data was collected and assisted by a resident doctor who was not involved with any patient care, and the sample was random and was collected from participants who came our hospital for various reasons, whether they had risk factors, previous history of myocardial infarction or simply as a relative of a patient or those who came for a simple check-up. Everyone had an equal chance of being requested to participate for the study. It takes around 7 minutes to complete the questions, and any query or difficulty in comprehending was cleared by a resident doctor who assisted the patient at every step of the process. Questions included demographic data, such as age, weight, height, education level. Past medical data were also collected, for instance, diabetes or hypertension history, and if there was any previous myocardial infarction. Knowledge, attitude, and practice questions were answered similarly with a binary yes or no, and each response was scored 1 and 0, respectively. In order to assess the reliability of the questionnaire, it was subjected to a pretesting process including a randomly selected sample. No notable language-related challenges were found throughout this procedure. --- Statistical Analysis The study employed IBM SPSS 24 for Windows. For continuous variables, descriptive statistics were reported as mean ± standard deviation , while for other variables, frequencies were employed. The scores of the participants pertaining to knowledge, attitudes, and beliefs were presented and analyzed. The highest attainable scores for knowledge, attitude, and practice were 22, 9, and 7, correspondingly. Moreover, the overall knowledge, attitude and practice scores was categorized into two distinct groups. For example, knowledge was considered to be sufficient for any result above 11, while 11 or less was considered insufficient knowledge. Furthermore, for attitude and practice we similarly scored them into two categories. 5 and less was considered poor attitude, while above was assigned as good attitude. For practice, scores 4 and less were considered inadequate practice, in contrast scores above were acknowledged as adequate practice. Associations between knowledge, attitude and practice with variable sociodemographic and health characteristics were assessed using Logistic Regression. For every analysis, we employed p < 0.05 to establish statistical significance. --- Ethical Consideration Due to the fact that our hospital is a research hospital an informed consent is obtained from every patient before giving them the questionnaire and assisting them in answering the questions. This study did not disclose any personal information. The study was approved by the research ethics committee of Mogadishu Somali Turkey Training and Research Hospital. The study was performed in line with the principles of the Declaration of Helsinki. --- Results --- Socio-Demographic Features In this study the data collected from 313 participants in the hospital for various reasons regarding their perceptions, attitudes, and responses towards myocardial infarction were analyzed. The mean age was 42 ±19 years of age. One hundred and seventy patient of the subjects were male, and 143 were female. Hypertension was the most common comorbidity in these subjects 64 , followed by dyslipidemia 41 and diabetes 36 . More than half of the respondents 163 did not have formal education. Only 12 had smoking history, and 14 had regular practice of Khat chewing. The mean weight of patients was 68±27 kg. Eighteen of the respondents had previous history of myocardial infarction. --- Knowledge Results The mean knowledge score of the participants was 11.07 ± 0.697, with a maximum score of 22. It was discovered that n=167, 53.35% of respondents did not know enough about myocardial infarction using the cut-off criteria . Out of those surveyed, 172 said that a clot-induced arterial blockage was the reason behind the myocardial infarction. Similarly, 187 participants, or 59.7%, acknowledged that MI may be lethal. Additionally, over 50% of the participants were aware that MI typically manifests as chest pain; only 131 were aware that MI might occasionally manifest without chest pain. Only 153 , 141 , and 141 of the respondents-or fewer than half-identified hypertension, diabetes, and dyslipidemia as risk factors for MI when questioned about their potential contributions. Sedentary lifestyle was identified as a risk factor by 129 and obesity by 137 . Moreover, the majority of participants did not regard weight --- Attitude Results The mean attitude score of the respondents was 5.086±0.3756. Using cut-off criteria, a slight majority of the patient showed favorable attitude. Almost 168 said they could recognize the symptoms of myocardial infarction. In contrast only 144 said they can recognize it in others. Furthermore, 154 believed MI is unpreventable, while 201 said they will accept a MI diagnose from a doctor. Lastly, 202 said they are ready to do whatever it takes to lower their risk of myocardial infarction. --- Practice Results The practice score average was 3.463259±0.352. Majority of the patient had inadequate practice and behavior according to the cut-off score. 168 of the respondents did not practice regularly or engage in any kind of sport. Only 119 of those questioned did not regularly check their blood pressure, sugar level or their cholesterol level. Majority of the patient did not also control their salt, sugar and fatty food intake. Noticeably, out of those who had diabetes and hypertension or dyslipidemia more than 75% of them did not comply with their medications. --- Factors Related to Myocardial Infarction Knowledge, Attitudes, and Practices In a logistic regression, the following predicator variables such as age, gender, educational status, and a history of diabetes, hypertension, and dyslipidemia were input as variables against the knowledge, attitude and practice scores to be analyzed. With the exception of one group, however, we did not find any significant associations between the various variables and the level of knowledge. It was discovered that participants who were male and had not received any formal education had a higher probability of having a lower knowledge, unfavorable attitude and inadequate practice level . --- DovePress --- Discussion In this discussion, we will compare Mogadishu's citizens' understanding, attitudes, and practices around MI with those of other parts of Africa and the globe. We will also investigate the causes of the differences and provide potential solutions. Numerous researches have looked at various groups' knowledge, attitudes, and practices about MI. For instance, research carried out in Tanzania discovered that just a small percentage of people there believed they were at risk of MI, and that everyone knew very little about the disease's symptoms. 8 This result was similar to our population findings. The prevalence of MI is rising throughout Africa. 9 However, a study that was carried out in three nations-the United States, Australia, and New Zealand-reported similar findings, with 56% of participants knowing enough about ACS symptoms. 10 Moreover, MI cases are rising in South Africa which many considers the most developed country in Africa. 11 These data show that improved MI prevention, education and management strategies are required in Africa. The relationship between health literacy and the management and prevention of cardiovascular disease is one crucial factor. The scientific statement released by the American Heart Association highlights the basic need of health literacy for both primary and secondary cardiovascular disease prevention. 12 Another study also demonstrated that health literacy is connected to healthy behaviors and self-reported health in people with cardiovascular disease, which further validates this. 13 These studies emphasize how critical it is to raise health literacy in order to increase understanding and encourage healthy habits related to MI. Somalia is believed to have a low health literacy due to years of civil war and poverty. According to a comprehensive review and meta-analysis by, attitudes toward Myocardial infarction have also been demonstrated to predict attendance at cardiac rehabilitation after an acute myocardial infarction. 14 A small majority of our patients showed a favorable attitude towards myocardial infarction. This may be due to a popular perception that heart attack is deadly acute condition in Somali culture. For instance, Patients' perceptions of their myocardial infarction can differ; according to a study by, some consider it to be an acute heart attack instead of a sign of a long-term illness. 15 Effective management of myocardial infarction necessitates a thorough understanding of and implementation of preventative techniques. 16 Diabetes mellitus, hypertension, dyslipidemia, and metabolic syndrome are risk factors for myocardial infarction. 17,18 Based on the cut-off score, most of our patients exhibited inadequate conduct and practice. 53.6% of the respondents, or 168 people, said they did not play any sport or exercised on a regular basis. Improvements in lifestyle, such as frequent exercise and physical activity, are essential for preventing cardiovascular disease. Physical activity has demonstrated benefits for cardiovascular well-being and can lower the risk of atherosclerotic cardiovascular disease. 19 Furthermore, most of the patients with chronic diseases did not comply with their medications in contrast to Seventy percent of hypertensive people in a Tshwane, South Africa research reported complying with treatment, while more than 80% of our hypertensive patients did not comply. 20 It is important to think about the effects of telemedicine, mobile technology-based lifestyle in order to improve knowledge and practice. People have seen telemedicine as a possible way to improve health care and practice, especially for people with heart diseases. 21 The use of mobile technology and smart devices has shown promise in changing the way people with a high risk of heart disease live, providing a practical way to enhance patient outcomes. These mobile technologies offer a way in which many people with the disease, risk factors or relatives of these groups can be educated. 22 Moreover, the internet provides a vast and extensive platform to access an audience of individuals who may have been previously deemed hard to reach. Sharing articles and videos about myocardial infarction can enhance understanding and influence behaviors related to this serious condition. Nevertheless, deceptive information can also be spread online. 23 To summarize, effectively addressing knowledge about myocardial infarction in Mogadishu necessitates implementing customized interventions that take into account cultural subtleties. It is crucial to utilize health literacy and technology to develop efficient strategies for prevention and management. --- Limitations of Our Study In our study we faced several limitations. First, there may be a limit due to the sample size and representativeness. Our study may not have included a representative and varied sample of the Somali population due to restricted access, which could have resulted in selection bias. Second, response bias is introduced by our data collection methods, such as surveys and interviews, as participants may give socially acceptable replies. This could result in an underestimating of bad https://doi.org/10.2147/VHRM.S448220 --- DovePress Vascular Health and Risk Management 2024:20 practices or an overestimation of knowledge and positive attitudes. Another issue with self-reported data is the potential for recollection or social desirability biases, which could skew the responses and effect data quality. Finally, the breadth of our study may be constrained by a lack of funding and time, which could have an impact on the number of participants or data collection locations. --- Conclusion In conclusion, our research highlights the serious gaps in the Somali community of Mogadishu's knowledge, attitudes, and practices surrounding myocardial infarction . To improve cardiovascular health awareness and management, the results highlight the critical need for focused health education, enhanced primary care, and community involvement. In order to close these gaps and guarantee that prompt and efficient interventions result in a healthier and better-informed Somali population, policymakers and healthcare professionals must work together. This will eventually lessen the incidence of MI in the area. --- --- Disclosure The authors report no conflicts of interest in this work.

Myocardial infarction and cardiovascular disease are significant global health issues, particularly in Somalia. The Somali population faces challenges due to armed conflict, limited education, and underdeveloped healthcare infrastructure. Cardiovascular risk factors like diabetes, hypertension, and obesity are prevalent, and Somali people face increased susceptibility. Methods: This study examined Somalia residents' perceptions, attitudes, and behaviors towards myocardial infarction using a crosssectional paper-based questionnaire. The sample consisted of 313 urban residents in Mogadishu, aged 20 and above. The questionnaire was written in Somali and was designed for the demographic. Knowledge, attitude, and practice scores were categorized into two groups, with associations between knowledge, attitude, and practice with sociodemographic and health characteristics assessed using Logistic Regression. Results: This study analyzed data from A random sample of participants who arrived at the hospital for various reasons regarding their perceptions, attitudes, and responses towards myocardial infarction. The mean age was 42 ±19 years, with 54% being male and 46% female. Hypertension was the most common comorbidity, followed by dyslipidemia and diabetes. Over half of the respondents had no formal education, and only 3.8% had a smoking history. About 5.7% had a previous history of myocardial infarction. The mean knowledge score was 11.07 ± 0.697, with 53.35% of respondents not knowing enough about myocardial infarction. The majority of the patients showed a favorable attitude, but only a slight majority could recognize symptoms of myocardial infarction. The majority of the patients had inadequate practice and behavior, with 53.6% not practicing regularly or engaging in sports.The research highlights gaps in Mogadishu's Somali community's knowledge and practices regarding myocardial infarction. It emphasizes the need for health education, primary care, and community involvement to improve cardiovascular health awareness and reduce MI incidence.

INTRODUCTION Among the regions of the globe, Africa is such a peculiar region with existential difference in the midst of the multitude of nations, regions, races and what have you. This is evidence in the location of the continent, the uniqueness of the race, the natural resources as well as human capital, distinguishing the region across histories. By way of comparison, among the so called developing nations, it is only in Africa that the American and European imperialistic institutions have found reliable human capital for sustainable development throughout the era of initial contact, slavery and even the modern slavery, which is currently ravaging Africa in form of looking for greener pastures overseas through the hypocritical visa lottery, work permit, japa and all the likes. This is also applicable in the distribution of natural resources, which are mainly located across Africa but are being exploited with impunity by the American and European league of imperialists. This article explores these issues in the context of social work and development in Africa. --- AFRICA, AN OVERVIEW Africa as a continent is home to more than 30% of the world mineral reserves, more than 8% of the world natural gas and more than 12% of world oil reserves. The continent has more than 40% of the global gold and 90% of chromium and platinum; 90% of the world cobalt, 60% of the world coffee, 70% of the world's cocoa, etc. According to Saifaddin Galal , the population of Africa is clocking 1.4billion with majority of the population being youths who are potential labour force and human capital for sustainable development. According to the ILO , Africa is the largest supplier of labour to America, Europe, China Canada, etc., via migration. This included in the health sector, financial sector, industrial sector as well as services sector. According to World Population Review , Africa has the highest number of member nations in the United Nations. Geographically, Africa is located within the tropic of cancer and that of Capricorn with moderate weather and structural base devoid of frequent natural disasters. In any case, Africa is naturally endowed for all round sustainability. However, the story about Africa on the intercontinental scene is totally opposite of its natural appearance. For instance, statistics shows that Africa has the largest chunk of the developing nations in the world, Africa is one of the continents permanently marked with poverty and backwardness, Africa is currently the destination of the majority of the global aid offering coming from Europe America and even other emerging economies from Asia, Latin America, Oceania and Caribbean . Africa from the North to the South and from the East to the Central and the West is all characterized by corruption, political instability, conflicts and poverty even in the midst of multiple natural resources and the huge donations from overseas . Although in the recent history, the world extant bodies have made some claims of liberating individuals, tribes, ethnic groups, race and nations from the domination and abuse by other superior individuals and groups, the African case is certainly different and most certainly, Africa seems to be out of such claims if at all it is obtainable anywhere in the world. The principle of the survival of the fittest and individualistic tendencies, which ravaged the European world and spilled over to America in the earlier centuries, seems to be holding down the global community especially after such found expression without challenge in the African continent via empire conquest, slavery merchandise, colonialism and the subsequent neocolonialism . The principle of the survival of the fittest and individualistic tendency, which found expression in the African continent through conquest for empire, slavery merchandise, colonialism and the current neocolonialism, eventually created a sustainable generational attack on the overall system of the African continent, leaving the system with a pathological abnormality . In Durkheim's parlance, which subsequently gained acceptance in the circle of social scientists and humanity studies, pathological society or system is marked by some characteristics of ill health in connection with the clinical terminologies of health . This is identifiable through social indicators of abnormality in the social institutions of the society such as family, economy, education, religion, culture, politics/governance, and their ineffectiveness in dealing with the overall needs of the society itself and the members of the society . Pathological system or society as can be observed currently in Africa is characterized by failure of the system to meet the needs of the human elements in the system, abnormal functioning of the components of the system, autoimmune crises such as human elements in the system becoming a tool to destroy the system itself, dependency instead of self-sustainability, degeneration instead of regeneration and other characteristics of ill health. Pathological condition is a symptom of pathogen attack on the system, which compromises the ability of the system to continue in a sustainable health. In the case of Africa, colonialism and neocolonialism have remained the major pathogens sustainably attacking the system and leaving the system in a pathological condition. Over the years and following consistent observations, the case of Africa seems to have defied every cure and healing strategies attempted so far due to deep rooted infection and cross-infections through the institutionalised colonialism and neocolonialism, which have operated covertly over the years and evaded the comprehension of the African nations and their leaders. However, the growing interest by African indigenous researchers who appreciates home grown methodological approaches in the recent times has unveiled the possibilities of healing the African system through the customization of academic disciplines as well as other social institution as trajectory of institutionalizing decolonization for effective and innovative outcome . As such, the possibility of healing Africa from her current pathological condition as a result of deep-rooted colonial and neocolonial infections is in sight with the promising power and engagement of African social scientists and social workers in particular who are more deeply involved in all aspects of social institutions and areas of life in African system. The aforementioned is the focus of this paper. --- AFRICAN PATHOLOGICAL CONDITION Pathological condition in clinical terms is observable disposition of a living thing showing unhealthy condition as a result of infection and the consequent diseases and decay in health and wellbeing. In social scientific parlance, this is a social condition showing the malfunctioning of the social institutions resulting to the general decay of the system and underdevelopment, with daring impacts on the members of the society in question. Africa in history and the present historical epoch is in pathological condition and the symptoms of these conditions are observable in her different social institutions and socioeconomic life. According to World Bank , Africa is the destination of global poverty with majority of the global poor living in African countries despite the arrays of natural and human resources. Africa is the destination of the countries with the poorest public institutions in terms of provision of basic services to her population despite supplying the world with labour in various sectors. This is visible in the health sector, the economic sector, educational sector, leadership and services sectors. Africa is the most underrepresented continent in the United Nations in terms of her interests and challenges in the current history despite having the highest number of membership in the organization. Across the global continents, Africa is the destination of the group of high ranking corrupt nations, political instability, religious crises, high capital flights to Europe, America and Asia as well as students and labour migration out of the continent. Africa in the current historical epoch exhibits all the symptoms and characteristics of what Durkheim called a pathological society . These ranges from the economy to the political system and the various public institutions established to manage the complex networks of human needs in the society. The symptoms of pathological condition of the African nations can be captured in the social indicators of the basic human needs, which are connected with the institutional structural existence of the states and regions. For instance, in the health sector, virtually all African nations cannot boast of sustainable healthcare for the citizens especially in connection with the basic human health needs and emerging health complications . Yet, the same African nations are the pool of human resources for the European, American and Eurasian health institutions . Worst still, most of the basic pharmaceutical and health products sustaining the overseas health industries are obtained from Africa however, Africa still remain the destination for substandard drugs and equally experience scarcity of pharmaceutical products . A statistical irony about Africa presently is that Africa is the major pool for human resources for Europe, America and Eurasian health institutions but, is classified as one of the worst regions in terms of health-workerspatients' ratio population density . Majority of African indigenous health workers trained domestically and overseas end up serving in the American, European and Eurasian health institutions following the perceived poor service condition at home and other envisaged discomforts. Within the economy of virtually all African nations, the principle of the more you look, the less you see seems to be overriding the system following the corrupted structures either inherited from the colonialists or induced by the neocolonialists. Virtually all African nations have not less than 5 mineral resources serving the needs of the global communities and being exploited from overseas however, the same African nations are on the top lists of nations depending on the Britten wood institutions for survival via borrowing and aid . From North Africa to South Africa, and from east Africa to Central and West Africa, virtually all the nations within these regions are under different borrowing formula and aid assistance from the Britten wood institutions, United Nations allied bodies and different colonialists and neocolonialist exploiters. These borrowing and aids are systematically conditioned to enslave the economy of the receiving nations to the givers, continue without end and sustain intergenerational domination of the economy of the receivers. And, these borrowing and aids by the former colonialists and neocolonialists are operating in virtually all the African countries currently. In any case, virtually all the economies of African nations are sick and struggling. Politically, across African nations, no nation can boldly make an independent policy from the United Nations allied bodies and the league of colonialists and neocolonialists without being reprimanded. The leaders of African nations are technically stooges of the colonialists and neocolonialists hiding under the cloak of Britten wood institutions and the compromised United Nations and her allied bodies. This is exhibited in the continuous and widespread anti-African socioeconomic policies by the leaders under the yoke of United Nations globalization agenda covertly sustaining the interests of the former colonialists' and neocolonialists' interests across African nations. The former colonialists and neocolonialists, technically undermined by the United Nations exploitation agenda are now using aids, allies and diplomatic smokescreen to penetrate and influence socioeconomic policies among the vulnerable African nations. All the public institutions established among the African nations such as education, banking, public health institution, commerce and industries, culture and public orientations, etc are all patterned to accommodate and please the European, American and Eurasian colonialists and neocolonialists. --- THE PATHOGENS OF COLONIALISM AND NEOCOLONIALISM IN AFRICAN SYSTEM Following the pattern through which colonialism and neocolonialism were institutionalised among African nations, the lifestyle of the subsequent generations has been automatically sequenced to build on the faulty foundations of the colonialists and neocolonialists ostensibly designed to keep Africa in perpetual dependence on the European, American and Asian nations while Africans are being exploited. This has resulted to self-hatred among the indigenous population of Africa due to comparison with the colonialists and neocolonialists values, African nations depending on the Britten wood institutions for borrowing and economic aids, Africa building her socioeconomic policies around the colonialists and neocolonialists socioeconomic models, maintaining public institutions that have no relevance to the indigenous people but aspires to meet the colonialists and neocolonialists global standard and political leaders in Africa being handpicked by the colonialists and neocolonialists to represent their interest against the overall interests of the indigenous population By 14 th century, the seed of colonialism and the subsequent neocolonialism had begun to germinate in the African region of the neoglobal map. This began with the empire conquest and natural resources colony in proxy by the European nations such as Spain, Portugal, Italy and Britain who were exploring the world for natural and human resources for the emerging industrialization that has greeted the world via the European and American economies who have made breakthrough against the hitherto agrarian society and mechanical society. As part of the enterprise of the American and European league of exploiters in legitimizing illegitimacy when it is a sure way of continuing unfriendly capitalistic tendency, the proxy conquest and resources colony was graduated into full blown macro scale system of exploitation, first as slave trade, which received acceptance among the majority participating in the business in Europe and America, and latter into colonialism approved and accredited by the European league of nations. The principle of the survival of the fittest, which has become a norm among the European and American League of Nations, seems to have permanently guided every intra and international relationship they have maintained. It was only a matter of compromising the image and intention of the activities involved in the relationship to capture whichever victim they came across. As such, the capitalistic tendency that pushed these nations to seek for materials and resources elsewhere compelled them to see the African nations at each stage as ripe for exploitation but by different strategies and approaches. For instance, during the era of conquest for empire and slave trade, they simply appeared as helping the trapped victims with rejected products in the European and American markets as well as, protecting the trapped population from the pseudo war they have invented. This superficial view of the initial contact was soon contradicted by the subsequent impunity with which they exploited the populations including the local leaders who ignorantly entered into alliance with them against their subjects. After the era of proxy conquest for empire and slave trade bowed to the prevailing moral pressure emanating from the self-inflicted injury the European and American did to themselves by activating the canon of human right consciousness, colonialism, which officially received the blessings of the European league of nations in 1884 in Germany began to take off the stage in the disguise of civilization and protection of the vulnerable and already trapped African territories. Europeans having encountered resistance at the earlier stage of the colonial conquest while using force and weapons, changed the strategy into deception of the population with the Greek foil of friendship and civilization ostensibly to compromise the social psychology of the population to ignore the inherent dangers of self-enslavement orchestrated by the colonialists. As such, the policy of assimilation and that of association were introduced to eventually make the population vulnerable to self-hatred, a situation that graduated to auto rejection and autoimmune among the African population till date . Colonialism itself was institutionalized via the social institutions, public institutions and public orientations such that, every aspect of African existence bowed to the infection of colonialism. For instance, the indigenous concept of security was transformed to modern institution so that the indigenous people were recruited to protect the interest of the colonialists, the indigenous concept of family was transformed to the colonialists home grown family ideology promoting individualism and segregation in the communities , indigenous concept of leadership was corrupted to promote the colonialists slave master ideology capable of sustaining the interest of the colonialists long after they have left the system , cultural orientation was corrupted with the quest to promote the colonialist culture and self hatred among the colonized , public orientation generally became a tool for the colonialists to subject the colonized to perpetual servantship to the colonialist system , etc,. The neocolonialism enterprise took the trajectory of institutionalised colonialism but with slight changes to adjust into the system that has been tensed by the agitation against the colonialist after colonialism got superseded by the prevailing moral order in the historical epoch. While the league of colonialists was within the wall of European nations, the web of neocolonialists included the former colonialists covertly maintaining their domination over their former colonies, and new entrants into the business of exploitation of the African and other nations who covertly used economic aids and other covert strategies to lure and tie down the vulnerable African nations. --- SOCIAL WORK AS SOCIAL HEALTH INSTITUTION AND SOCIAL WORKERS AS SOCIAL HEALTH WORKERS Social work as a profession and discipline emerged as reaction or rather counter measure to the observed and envisaged social dilapidated condition of the time in Europe and America . While the social dilapidated condition is perceived as a social scientific concept to capture the abnormality in the society affecting the population, the social indicators were the visible suffering of the population in different areas of life. As such, social workers' corporate social responsibilities, which culminated into social work profession and specialized disciplines was the invention of the necessity of assistance to the poor masses lacking access to the basic social support and available resources for survival . Social work by its appearance in all areas of the socioeconomic life of the society can best be captured as social health institution with much emphasis on its responsibility in dealing with the pathological condition of the society. While the pathological condition of the society exhibits the symptoms of diseases in different aspects of the societal life, social work as social health institution appears as multifaceted institution specializing in dealing with the different diseases dealing with the society itself. Clinically, there are different health condition and dimensions of health, which warrant specializations in the medical profession; this situation is obtainable in the social system, warranting the different specializations in social work, which deal with different issues in the society affecting the social wellbeing of the human beings in the society. In the social scientific parlance, the different challenges faced by the poor masses in the society, which prompted the activities of the social workers are all social health issues requiring some professional training and understanding to deal with them in other to bring about social wellbeing for the population. Social work specializations, which are numerous such as in the areas of management, advocacy, policy and planning, public welfare, social justice, leadership etc., are typically designed to bring solution and ensure wellbeing of the population in these different dimensions of human existence. These different dimensions of human existence are supposedly social indicators of wellness and social pathology, which required social health specialists to bring about wellness of the population. This goes with the problem of colonialism and neocolonialism, which are developmental and policy crises dealing with the African system in the current historical epoch. While colonialism and neocolonialism are diseases and pathogens that have infected and continued to deal with the African system, the symptoms are the indices of underdevelopment and system degeneration, which we have continued to observe, experience and complain about. These are health and pathological conditions waiting for the social work health institution in the current history of Africa. Social work came as a healing service to humanity but started mostly as affairs for the poor. However, with time the realities of the essence of social work services for the vulnerable such as the African population has gradually emerged as the specialization in the social work profession has begun to explore the strategic areas of African vulnerabilities before the league of global imperialists. Social work as social health institution implies that the activities of the social workers are geared towards healing the society from different diseases and health conditions including pathological condition as Africa found herself currently. The healing of Africa from colonialism and neocolonialism can be achieved through the specializations in social work profession, which tally with the different areas of African colonial and neocolonial problems such as in the areas of educating the youth, public policy, leadership, social justice, monitoring and management of foreign aid and the likes. --- Institutionalizing Decolonization in Africa: the expected Surgical Intervention by the Social Workers Unusual disease cannot be cured by everyday medicine. Colonialism and neocolonialism are not common developmental problems, which the theory of sustainable development by the United Nations can deal with owing to the fact that the phenomenon of colonialism and neocolonialism were properly designed perhaps by the same League of Nations who designed the theory and agenda of sustainable development. Colonialism and neocolonialism were perfectly institutionalised to capture every aspect of African existence for continuous bondage from generation to generation. As such, there is a need to set up a counter institutional process to reverse the domination and manipulation of colonial and neocolonial imperialistic activities. Social work as social health institution is perfectly positioned to do this in Africa. Decolonization agenda is more complex in application than they appear in concept and assumptions owing to the high level of intelligence behind the colonization and neocolonization processes. Colonialism and the subsequent neocolonialism did not just appear in African system and started ruining the system without a coordinated and high intelligent works by the colonizers and the neocolonizers who designed the game. Beginning from the era of conquest for empires to that of slave trade, colonialism and the current neocolonialism strategies, they were carefully crafted system of imperialistic mission with multiple dimensions to capture African population virtually in all dimensions of life. While some of the dimensions of this imperialistic agenda were imported from the colonialists' territory, others were developed in the field of imperialistic mission following the principle of necessity is the mother of invention. In any case, the colonialists and the neocolonialists applied inductive and deductive strategies in managing their imperialistic mission in Africa. However, the most complicated level of the colonialists and neocolonialists operation in Africa was the institutionalisation of colonialism and neocolonialism in Africa. Institutionalisation of colonialism and neocolonialism in African system followed certain processes and trajectories to capture and eventually enslaved the entire African societal system including the non-colonized territories who eventually were captured in the ongoing neocolonialism agenda. The processes included the basic learning processes such as capturing of the attention of the population, imbuilding the colonialists covert agenda in the memory of the population, subversion of the indigenous languages for the colonialist and neocolonialists' languages, elevating the colonialists and neocolonialists logical order in the life pattern of the population, subjecting the colonized and neocolonized to the writing pattern of the colonialists and the neocolonialists as well as enslaving the thought pattern of the colonized into the colonialists and neocolonialists agenda. These basic learning processes are naturally occurring but are vulnerable to whoever wants to manipulate them for whatever agenda such that through these processes, one can develop a population or a generation that will destroy itself in ignorance. The colonialists and the neocolonialists utilized these learning processes to gradually and steadily enslave the African system to make a way for their imperialistic agenda in the socioeconomic life of the population. They utilized the two major institutional and quasi-institutional trajectories to actualize this among the African population during the colonial period and the ongoing neocolonial historical epoch. These trajectories included the educational institution and the public orientation institutions such as the public media, work situation orientation, career orientation, religion and other tertiary orientation avenues among the population. Through these trajectories, the colonialists and the neocolonialists eventually developed an army of ignoramus who deliberately sustained the colonialists' and neocolonialists' agenda regardless of the disastrous consequences of the agenda on their side . This system of colonialists' and neocolonialists' institutionalization of their imperialistic merchandise has lasted beyond the initiators and become a regular thing that has replicated the population of pro colonialists and neocolonialists interests in African system. Having observed the colonialism and neocolonialism as pathogens and diseases in the African system, and how these pathogens and diseases found their way into the system, there is a need for sustainable strategies by the social health workers to heal the system. The surgical intervention by the social workers in dealing with the current pathological condition of African system as social health workers begins with the understanding of the processes and sustainable factors of colonialism and neocolonialism and how to reverse these factors in the system. However, for sustainable effects, whatever workable strategies to be adopted, they must be institutionalized. Institutionalisation of decolonization is the process of regularizing sustainable strategies in public counter measures against colonial and neocolonial orientations among the victims of colonialism and neocolonialism. The surgical intervention by the social workers as social health workers in healing the African system from its present pathological condition spans across the areas of specializations in social work discipline. In any case, social workers can use their professional specializations, which touch all social institutions of the society and virtually all aspects of life, to penetrate and sanitize the African system. These include the creating of avenue and establishment of sustainable educational program within the educational institutions to regularize counter colonial and neocolonial orientation among the youth and the users of educational resources and services among African population; capturing the public orientation institutions such as public media, career orientation process, work situation, etc., through advocacy to sustainably reverse the thought logic of colonialism and neocolonialism among the population; penetrating the policy initiation and implementation processes, with Afrocentric orientation and counter colonialists and neocolonialists orientations; building and popularising teams of Afrocentric leaders at various levels of leaderships among the new generation leaders in order to phase off the already muddled leadership system in Africa, capturing and reversing micro and macro scales foreign aids from colonialist and neocolonialist intension, into indigenous African resources for genuine and sustainable development activities. --- CONCLUSION The African system captured as the social, economic, cultural and political lives of the African nations has been subjected to sustainable attacks by the so called developed nations and even emerging economies in a manner best understood and expressed in this paper as pathogen attacks resulting to pathological condition. These attacks have basically come from the league of the former colonialists and neocolonialists who covertly entrench themselves into the systems of the African nations via Britten wood institutions, economic aids and vertical bilateral relationships with the vulnerable African nations. Over a century, scholars, political elites and even the common masses have tried in different times, strategies and dimensions to liberate African nations from this illicit engagement however, there has been some level of complications invariably making it difficult to ordinarily deal with the situation. The complications have virtually hanged on the fact that the whole issue of colonialism and neocolonialism was a system institutionalised beyond one individual, group or nation, but operated across regions, time and fluidly interwoven with the life system of the colonized and the neocolonized. Meanwhile, unusual disease can only be cured by unusual medicine; this is applicable to the current condition of the African nations. The unusual medicine for the pathological condition of the African system is domicile with the social workers who are exceptional in dealing with social problem. Social workers are perfectly positioned with their strategic relationship with the poor mass across African nations who are in the majority of the population analysis of African existence and also are more vulnerable to the impact of colonialism and neocolonialism. This they can achieve exploiting the multidimensional approach to societal social wellbeing captured in the specializations in social work profession.

Africa, conceptually, geographically, politically, economically, religiously and socially is in bondage and this bondage is summarized as pathological condition. The pathological condition of Africa is the outcome of cumulative of the attacks by the empire builders, slave traders, colonialists and the neocolonialists. The attacks and their consequences on the African system have resulted to the continuous failure of the socioeconomic, political and institutional lives of the African system with such symptoms and social indicators like political dependence on the colonialists and neocolonialists, dependence on foreign economic aids and borrowing galore, social segregation and self-hatred among the African population, modern slavery by willingness, political instability, religious exploitation, etc. Over the years scholars, political elites and other categories among African population have tried to deal with the pathological condition of the African nations however, the situation seems to have defied every strategy. This defiance of the pathological condition of the African nations to almost every effort to reverse it lie in the way and manner the adventure of colonialism and neocolonialism was designed and implemented. Colonialism and neocolonialism were institutionalised and eventually sustained using the indigenous population. As such, decolonization can only be successful if it is institutionalised and operated by the elite class with deep knowledge of the problem and deep relationship with the African population. Hence, the social workers with their multidimensional discipline and profession as well as deep interaction with the population are strategically handy in mounting and sustaining decolonization agenda in the 21st century Africa. The aforementioned is the focus and interest of this paper.

INTRODUCTION Studies of culture change have paid attention to the change in the level of national values , but few studies have been conducted on the relationship between the change and health of residents . We argue that change in the socio-demographic conditions would undermine individuals' psychological health, because whereas human well-being is a function of habituated behavioral tendencies fitted best to accustomed context, change will bring alterations to the requirements of the external environment. We believe such process is apparent across national boarders. In this study, we focus on the typical case of socio-demographic change which took place in Japan. After the economic crisis known as the collapse of the bubble economy, 1 Japan has witnessed increasing societal problems, and this has led to investigations on the relationship between culture change and health . In this study, we take the perspective that Japanese culture, especially its socio-demographic context is becoming more nontraditional , and the change in context from 1990 to 2010-the two decades of extremely low rate of new employment opportunities, spread of new liberalism, and market 1 A surge in the market caused by speculation regarding a commodity which results in an explosion of activity in that market causing vastly over inflated prices. The prices are not sustainable, and a bubble is usually followed by a crash in the affected sector. In the Japanese case, land prices first inflated and then crashed. globalization -would negatively explain the health of Japanese adults. --- THE WORLDWIDE TIDE OF CHANGE The world shift toward Gesellshaft ) or socio-demographic condition common in individualistic societies is one of the largest contextual changes surrounding recent human ecology. Starting from economically developed countries, urban population, internet users, one person households, divorce, and national affluence are increasing throughout the world. Conceptually, we regard these changes as indicating the change toward increased Gesellshaft socio-demographic condition. Figure 1 shows a world summary of the changes, summarized from the database of OECD , United Nations Economic Commission for Europe , and World Bank , from 1990 to 20102 . Across the nine indicators, average ecological correlation with time was r = 0.94 , suggesting that these variables are changing worldwide with time. The change stimulated national development in many countries, fulfilling our needs of the modern life style . However, during the same period, many developed countries have also been caught up in waves of recession, leading to disparity in the population. During this period, worldwide economic stagnation occurred in East Asian countries in early 1990s, and in European countries during the late 2000s. There were some serious health consequences for marginalized group, such as unemployed, uneducated, or poor individuals during the time. However, economic turmoil may also affect the health of population at large, via the change in peoples' socio-demographic conditions. --- PSYCHOLOGICAL CONSEQUENCES OF CHANGE Historically, the socio-demographic change toward Gesellshaft secured free market and wealth leading to material possession and happiness . However, since socio-demographic change, by definition, takes place first in the external environment, it always precedes psychological change . Because human cultural adaptation is built even at the level of automatic behaviors learned in accustomed daily activities , change in the socio-demographic context would impose an implicit challenge to the efficiency of acquired pattern of behaviors. If acquired behaviors were rendered useless to pursue valued goals in life , our well-being would be compromised. In other words, our health is usually sustained by the culture we live in Diener , Draguns andTanaka-Matsumi , andTriandis , but for this very reason, sociodemographic change undermining the original can cause mental health problems in the population , by creating unaccustomed mandates . If the transition had been carried out smoothly, involving wellstructured institutions and formal education that supports people to catch up with the new requirements, the change into Gesellshaft socio-economic condition may foster independence and also preserve healthy social relations . However, when the transition is rapid, imminent, allowing no choice but to engage in global competition to survive, general population would fail to adapt. Further, if the original culture was encouraging interdependent ways of life, rapid change into Gesellshaft socio-demographic condition might require extra mental effort for the residents . Possible disadvantages due to such change may range from psychological to social aspects of their health. Specifically, their general health might be compromised because their working conditions become worse in response to economic stagnation. During this period, full-time employees were required to oblige by meeting an intensified workload, and they faced a doubled unemployment rate . Their life satisfaction might be lowered because subjective well-being can be compromised when valued life domains fail to satisfy individuals due to economic turmoil . If rapid change requires the members to be alone and exercise new self-ways to be accepted, change might compromise one's self-worth, or the fundamental motivation to belong and one's achievement/acceptance of socially desirable self . Perceived social support might also be compromised as change may increase one's need to relocate and be mobile in the new context . Isolated from supportive others, one's perceived social support may decline. In East Asian countries, the outcome of the change has been observed as a decrease in average psychological health. For example in Japan, people have traditionally regarded interpersonal harmony as their central meaning of happiness . Now they have to leave their close families, elder parent or friends in order to attain new position or decent job, sometimes they are involved in an aggressive competition or candid quarrel against their colleagues in order to compete for status and limited wage. Otherwise, they may give up making new family out of inflated partner choice and economic/business reasons. These events might increase the likelihood of interpersonal concerns or disharmony. Especially for those having interdependent self, the change might undermine their wellbeing, or severely limit the fulfillment of the motivation to belong. Given these disadvantages stemming from the glitch at sociodemographic level, some people may survive the influence using specific forms of positive strength. As one of such strengths, we focused on interdependent happiness3 . Interdependent happiness is a collectively shared concept of happiness among the members of interdependent cultures. According to the previous studies , Japanese, compared to European American counterparts, share the meaning of happiness as relational. Whereas this type of happiness is held central to the subjective concept of happiness among certain cultural members, the conception of happiness as relational is considered common across all human being. Because interdependent happiness involves relational harmony, quiescence and ordinariness , these positive meanings would be more central to residents' well-being in the Gemeinshaft societal condition. If the change is an avalanche toward Gesellshaft socio-demographic condition, then the traditional interdependent happiness would be a positive buffer against the trend. Therefore, among the traditionally Gemeinschaft societal members, the strength of preserving harmony among close others may find the negative influence of change. Particularly, in Japanese case, interdependent happiness will predict health positively while the change will not. --- AFTERMATH OF RECESSION IN JAPAN During the 1990's, Japanese companies faced a collapse of the collectivistic working style, together with the collapse of the real estate bubble economy. In the workplace, companies abandoned the lifetime employment and seniority system, in exchange for thrift management4 . The push for globalizing economy: transparency, international competition, and global communication increased. Even after 2000, the aftermath of this decade and further economic depression delayed Japan's economic recovery. Even more tragic was the fact that, although such change was apparent, formal education continued to encourage generalists: all-arounders capable of managing multiple roles in a single company, thus best functional under the long-lasting employment system 5 , and the major companies preferred naïve freshmen over slightly older professionals as their main labor force. Coinciding with such tension was an increase in health problems. The decades after 1990s are marked as a time when Japan showed unprecedented deterioration in mental health statistics . Following the bubble collapse, over 30,000 workers per year committed suicide. Specifically, the suicide rate of working men in their 30's and 50's increased. The number of outpatients diagnosed with mood disorders doubled between 1990 and 2010. The number of working adults suffering from depression increased, with more people suffering from depression than cancer or diabetes. From the late 1990's to 2010, applications for insurance compensation to workers were dominated by requests from patients with mental disorders , and industrial safety and health issues became focused on regulating overwork . Given this situation, the Ministry of Health, Labor, and Welfare listed mental disorders as one of the big five diseases among Japanese adults in 20116 . The decades after 1990 were a time when the lack of fit between traditional interdependence and the requirements of the new liberal, global economic, individualistic environment became apparent, with critical consequences for Japanese health. Kitanaka vividly portrays these adverse psychological profiles of Japanese workers and a "society in distress" through narrative data. --- HYPOTHESIS What are the psychological consequences of economic stagnation accompanying demographic changes away from the traditional way of life? In this study, we used a national case approach and focused on Japan as a country where people have traditionally lived in Gemeinschaft socio-demographic condition, but now caught up in a rapid change as a consequence of the 1990s . Specifically, we hypothesized that among those working adults who underwent large change toward individualistic sociodemographic condition, their psychological health would be more compromised than those who underwent small change . We tested this hypothesis by comparing different regions that systematically differ in the amount of change. --- Dependent variables We measured adults' health according to the indicators of general health, life satisfaction, self-esteem, and perceived social support. We hypothesized that the change would negatively predict general health . Also, change will negatively predict life satisfaction , self-esteem , and perceived social support . We divided social support into support provided from one's community and support provided from out of one's community, in order to explore the possible difference between these two. Finally, interdependent happiness would positively predict psychological health . --- Independent variables In this study, we use the term "change" to refer to a set of changes in socio-demographic variables related to societal level individualism-collectivism , such as family size or divorce. Specifically, the change is captured as a cross-temporal change during 1990-2010, and a change which took place at the level of socio-demographic condition. Therefore, we operationalized change as the difference in scores between two or more fixed points in time . We examined change using ecological correlations between our indicators discussed below and time . We measured socio-demographic conditions both at the meso and micro levels , and used change at those levels as additional contextual explanatory variable. In order to compare groups of Japanese adults varying in their degree of change, we used prefecture difference . Yamawaki measured at Japanese prefecture 7 level: the Japanese Collectivism Scale . The JCS is a sum of standardized scores of divorce to marriage ratio , percentage of households with three generations living together, percentage of elderly people living alone , percentage of nuclear family households , and percentage of people living alone in 2006. Communities also vary by how people make living within their ecologies and they show sizable group differences . We considered worthwhile to examine the impact of change at smaller levels than prefectures from the viewpoint of community-based policy making . We created a JCS city level variable 8 by aggregating the JCS indicators at the city level 9 . 7 Prefectures in Japan are the officially defined local governments that support citizens' efficient political administration and development of an area. They originate from the boundaries between local warlords during the Edo era that lasted for 300 years, until late 19th century. They are treated as inclusive geographic regions that have distinctive natural and unique historical aspects such as resources, main industries, or dialects. 8 Based on the argument by Na et al. , andHofstede et al. , we expected systematic differences in the reliabilities of JCS and JCSCL. Using various behavioral measures that replicated Japanese and European American differences, Na et al. found these measures to be uncorrelated with each other within nation, but correlated at the national level, demonstrating a cross-level difference in the reliability. Hofstede et al. also used his value survey module in a survey of Brazilian states, and poorly replicated his cross-national level factor structure at the cross-state level. If these studies are showing that national level indicators do not always hold at lower levels of analysis, collective behaviors such as percentage of people living with parents or divorce rate may be strongly correlated with each other, thus reliable, at most at the national level . But, once the same societal behaviors are collected at the lower prefecture or city level, the same indicators may lose their reliability accordingly because of the loss in "appropriate" level of analysis. Therefore, if we calculate JCSCL at the city level, we should expect even lower reliability and validity than Yamawaki 's JCS. Based on this reasoning, we tested the reliability and validity of JCS and JCSCL, hypothesizing that the former would be larger than the latter. 9 Cities in Japan are officially the most basic individual unit of local government, and their range is defined by population size and concentration of residences. Normally a city is led by a mayor, and each unit has its own board of education to administer formal schooling. While prefecture is rooted in a historical and geographical divide, the city is one of the closest and most rooted living units for residents in Japan. Traditionally, neighbors sharing the same city had specific as well as unwritten norms to oblige and help each other on ceremonial occasions such as marriages and funerals, in exchange for a daily commitment to district matters through assigned roles for each house. Even today, households often have some assigned roles in city affairs such as gatherings or athletic meetings, and people interact face-to-face with their neighbors and most children are formally educated at local schools located within each city. We evaluated societal level explanatory effects after controlling for basic individual difference variables. For those, we controlled for personality traits , gender , age and income in the analysis. As for income, considering the gender distribution of labor altering the income opportunity of adults in Japan, we measured own income independent of partner's income, and controlled these two in the analysis. In order to test our model, we first calculated the extent to which each prefecture and each city have changed using archival data . We then used those change scores to explain the health of residents living in diverse areas in Japan using social survey . --- STUDY 1: MEASUREMENT OF PREFECTURE AND CITY LEVEL CHANGE First, we examined how JCS changed between 1990 and 2010. Second, JCSCL and their changes were measured. We tested reliability and validity using criteria that are both available at the city level. Because the change after 1990s should have affected both urban and rural regions during this special period of economic disaster and globalization , we expected change in both urban and rural prefectures. --- METHOD --- Prefecture change We collected archival data on five indicators of the JCS for 47 prefectures in Japan from Japan's official census statistics site at 1990, 1995, 2000, 2005, and 2010. We used JCS at 2010 as a prefecture level Individualistic-Collectivistic socio-demographic condition score in this study10 . The five indicators included divorce to marriage ratio, percentage of households with three generations living together, percentage of elderly people living alone, percentage of nuclear family households, and percentage of people living alone . A total of 1,175 data points were collected. We calculated internal consistencies for every sampled year. We aggregated the standardized subtraction scores of each indicator between 2010 and 1990 as an indicator of change. --- City change Five indicators of JCS were collected at the city level from the same archive 11 . We tested reliability of the JCSCL by calculating internal consistency for every sampled year. We evaluated validity of the JCSCL using correlations with the city level variables of taxable income, percentage of adults working in primary industry, percentage of adults working in tertiary industry, move-in rate, and move-out rate, following past research . Then, we calculated cross-temporal change of JCSCL. --- RESULTS AND DISCUSSION --- Reliability of the JCS The reliability of the JCS indicators in each sampled year was marginal to acceptable as in the original study 12 . --- Changes of prefecture socio-demographic condition The first column of Table 1 shows the correlation between socio-demographic indicators and time at prefecture level. In four out of five indicators, their changes were in the direction of increased individualistic socio-demographic condition. However, for percentage of nuclear family, the trend showed reversed tendency, indicating marginal change toward collectivistic socio-demographic condition. Closer examination revealed this reversed correlation to be limited to urban prefectures . This indicator change may be related to the population increase in urban areas, however, in this study we followed Yamawaki to use this as an indicator. Figure 3 shows representative change for each indicator. The urban and rural groupings were made based on the number of households and gross domestic prefecture income. Within that variation, the top four urban and rural prefectures that are located apart within each group and have closely located pairs across groups were selected, and their JCS scores were averaged in 1990 and 2010, respectively. Both urban and rural prefectures showed trends toward individualistic socio-demographic condition, except for percentage of nuclear families in urban areas. The JCS and its change score correlated positively , indicating prefectures with collectivistic socio-demographic condition showed more change during this period. In Figure 4, a bar describes the sum of standardized change across indicators for one prefecture, or the degree to which a prefecture changed into individualistic socio-demographic condition in comparison to others. The rate of change differed across prefectures 13 . --- Reliability and validity of the JCSCL As in Yamawaki , the JCSCL also showed geographic similarity between the neighbors; for example, those cities located around the Sea of Japan coastal area are generally collectivistic, pointing to the possibility that city level socio-demographic condition is clustered geographically . The reliability of the JCSCL was lower than that of the JCS in every sampled year. Similar to the JCS, there was also a declining trend of the reliability over time. The validity coefficients were r = -0.11 with income, r = 0.11 with workers in primary industry, r = -0.44 with workers in tertiary industry, r = -0.36 with move-in rate, and r = -0.40 with move-out rate, all in expected directions. These indicate reasonable relationships between criteria variables and the JCSCL; yet, they show lower validity coefficients than those of the JCS 14 . --- Changes of city socio-demographic condition The second column of Table 1 shows the correlation between socio-demographic indicators and time at city level. All indicators changed in the direction of increased individualistic socio-demographic condition, with percentage of nuclear family showing weaker correlation than other indicators. The changes in the JCSCL scores also varied between communities 15 . The JCSCL and its change score were very weakly correlated , or in other words, city level socio-demographic condition was weakly related to its change during this period. 13 Akita, Toyama, or Tokushima, prefectures that had large population and had neighboring prefectures that were more urban, seem to have changed greatly during the period. In turn, Okinawa and Kagoshima, the most southern prefectures in Japan, showed smallest change. In addition, Tokyo and Kanagawa, two of the most modern prefectures, showed the least change during the period. 14 Validity coefficients of the national cultural indicators might greatly attenuate at lower levels such as cities. A similar case was found when national level indictors were collected to examine city level difference in U.K. . However, such low level of reliabilities throughout different years would indicate that either the concept of Individualism-Collectivism is not best applicable to describe city differences, or measurement error is unavoidable when locating city level I-C using this specific set of indicators and we need to come up with different indicators at lower levels . 15 For example, the largest change toward individualistic socio-demographic condition took place in Ri-shiri town at the northern island of Hokkaido prefecture, where single living increased from 10% to 40% within two decades. In turn, the largest collectivistic change was observed in A-guni village in Okinawa prefecture, where the percentage of elders living alone decreased from 27.23% to 16.67% within the period. In Study 1, we measured socio-demographic indicators by prefecture and city, and have observed variation in change. Utilizing this variation as a comparison ground, we conducted Study 2 to examine if Japanese subjective health would differ significantly depending on the degree of change. --- STUDY 2: EXPLAINING ADULT HEALTH FROM CHANGE, PREFECTURE/CITY SOCIO-DEMOGRAPHIC CONDITIONS, AND INDIVIDUAL DIFFERENCES We surveyed Japanese adults living in various prefectures in Japan, and tested the hypothesis model . --- METHOD --- --- Measures For the explanatory variables, we used the Interdependent Happiness Scale , which consists of 9 items asking whether participants experience happiness in their interpersonal relationships. Items included statements such as, "I believe that I and those around me are happy," or "I feel that I am positively evaluated by others around me." Participants responded using a 5-point , Likert-type scale. The regression weight for this scale score on health measures would respond to our hypothesis 5. We used the Temperament and Character Inventory to measure the personality difference. Because of limited space for questions in the joint survey, we used 2 or 3 representative items that have shown high loadings in the past Japanese study, to tap each of the 4 dimensions of temperament. Examples of TCI items were, "I like to use money rather than save it ," or "I often get nervous or worried when doing new things I am not familiar with ." Participants responded using a 4-point , Likert-type scale. We also asked about participants' annual income, including the annuity, from both the self and the partner as a measure country ; therefore, the results should not be understood to cover full range of prefecture variation in Japan. Despite this limitation, a wide age range from working to retired adults who had been working during 1990 to 2010 were obtained, which is valuable for the purpose of this study. of economic condition. Because Japanese adults have large gender differences in working roles, we asked these two separate questions and analyzed by controlling for gender. We asked participants to choose one option from 0: no income, 1:-3.99 million Yen , 2: 4-5.99 million Yen , 3: 6-7.99 million Yen , 4: 8-9.99 million Yen , 5: more than 10 million Yen , separately for themselves and their partner if they were married. To test our hypothesis 1, we used the General Health Questionnaire . Examples of items from this questionnaire are, "I couldn't sleep well, because I had worries," or "I was able to have more fun in my daily life than usual." Participants rated how they felt/experienced each day using a 4-point Likert-type scale. To test hypothesis 2, we used the 5-item Satisfaction with Life Scale as a measure of subjective wellbeing. The SWLS consisted of items such as, "I am satisfied with my life as a whole," and participants responded as to whether they would agree to each statement using a 7-point Likert-type scale. To test hypothesis 3, we used 2 indicator items tapping selfliking and self-competence aspects of self-esteem as a measure of global self-evaluation . Participants rated how the items applied to themselves using a 5-point , Likert-type scale. To test hypothesis 4, we asked about one's perceived social support, both in and outside of one's community, since working and retired adults might have significant others in or outside of the area in which they lived. The question was, "To what extent do you have friends/acquaintances whom you can help or talk to each other?" We asked them to rate separately, "friends/acquaintances in the community " and "friends/acquaintances out of the community," on a 3-point scale . Before analysis, scores of GHQ and social support were reversed so that a higher score means better health. For the rest of the scales, higher score indicates better health. Descriptive statistics and reliabilities of the scales are listed in Table 2. Except the four TCI subscales, which showed marginal reliabilities , other measures showed acceptable levels of reliability. Explanatory variables were weakly correlated with each other . --- Analysis For each of the dependent measures, we used the same set of explanatory variables . In the model, the first level explanatory variables were, age, gender, four temperaments , and interdependent happiness. Second level explanatory variables were the 53 JCSCL scores assigned for available communities/cities and the degree of their change from 1990 to 2010. Third level explanatory variables were the 17 JCS scores assigned for available prefectures and the degree of their change from 1990 to 2010. First and second level explanatory variables were group mean centered. The higher level explanatory variables were modeled to explain the intercept of their lower level. Therefore, the model tested would be described as follows. Level-1 Model: Health measure = P0 + P1 × + P2 × + P3 × + P4 × + P5 × + P6 × + P7 × + P8 × + P9 × + e Level-2 Model: P0 = B00 + B01 × + B02 × + r Level-3 Model: B00 = G000 + G001 × + G002 × + u Because each participant was nested within prefectures and cities, we first examined how much variation in our dependent variables would be accounted for by group differences per se using intraclass correlation . We used the HAD program to calculate the ICC and conventional F ratio comparing the variance within and between the prefectures for each of the dependent variables, separately for prefecture and city . Given the fact that the typical ICC in applied research is around 0.02-0.22 , there was very little group difference between prefectures or cities. This would indicate that when using self-reported health data among Japanese adults, there are almost negligible differences between prefectures and cities compared to the individual variation within them. With these small effect sizes in mind, we conducted Hierarchical Linear Modeling using HLM7 . --- RESULTS AND DISCUSSION The results show strong and stable relationships between individual difference variables and health, and small but significant effects of change . This indicates that Japanese health is explained largely by individual level factors, and to a lesser extent, by the temporal change of socio-demographic conditions at both prefecture and city levels. In addition to such a general association, there were differences in the combinations of these societal variables affecting specific health-related variables . Contrary to our hypothesis 1, general health was not explained by change, but was explained more by individual age, gender, harm avoidance and reward dependence, and interdependent happiness. Supporting our hypothesis 2, satisfaction with life was low among those who live in changed prefectures , but city level change did not show the same weight. Supporting our hypothesis 3 weakly, self-esteem also tended to be low in changed prefectures . Negative weight of JCSCL on selfesteem might reflect a relationship between collectivism and low self-esteem . However, these predicted effects were smaller than the individual differences in harm avoidance, persistence and interdependent happiness, suggesting that subjective well-being and positive self-regard are largely predicted by individual emotional predispositions and interdependent happiness, if within-country difference is concerned. As for hypothesis 4, social support in one's community was not explained by change, but tended to be higher among collectivistic socio-demographic prefectures, and high among such communities . Social support out of one's community was negatively explained by prefecture change , suggesting deterioration of distal support during this period. Collectivistic socio-demographic prefectures, but not cities, showed lower support from outside of one's community . Again, individual level factors predicted social support significantly, and harm avoidance and reward dependence, as well as interdependent happiness, were the significant predictors of social support. Supporting our hypothesis 5, in all health measures examined, interdependent happiness showed positive explanatory weight. This is an indication that interdependent happiness-relational harmony, quiescence, and ordinariness among Japanese adultsis an integral part of their health, independent of change during this period. --- GENERAL DISCUSSION In this study, we examined the relationship between sociodemographic change and health, using Japanese adults living in various prefectures and cities. We tested whether the change pertaining to the increase of individualistic socio-demographic condition is related to health during 1990-2010, when the Japanese economy and culture was undergoing massive economic turmoil . As a result, most of our hypotheses were supported and some were not. That is, hypotheses 2 regarding the negative prediction of life satisfaction was supported and hypothesis 3 on self-esteem was weakly supported. Also, hypothesis 5 which stated the positive prediction of interdependent happiness onto health measures was supported. Regarding hypothesis 4 which stated the negative impact of change onto perceived social support, showed mixed results. That is, change at the prefecture level did relate to less perceived social support out of one's community, but did not relate to that of inside of one's community. Finally, hypothesis 1 with regard to the negative prediction of change onto general health was not supported. Considering the overall pattern of results, the consequences of economic turmoil might be related to self-evaluative and the social domain of health. --- Pan-cultural implications The present findings support the argument that rapid sociodemographic change can be related to psychological difficulties . We may be able to extend such argument by focusing on the socio-demographic change and consider adult health. Also, the result suggests the importance of cultural well-being as a psychological strength, and basic individual difference in sustaining the health, since the best predictors of health were interdependent happiness and personality17 . If individual differences are in turn sustained by the larger national culture , then both personal and social explanations may need to be used together to explain adult health. Future studies will need to clarify more concrete processes of this contextual aspect of our health, such as how, and what events surrounding the individual would mediate this cross-level impact on health. --- Implications for Japanese culture Current results showed that the socio-demographic change which took place during this period was negatively related to the Japanese well-being. Specifically, in more changed prefectures, such as Akita, Tokushima or Toyama prefectures, adults are more unsatisfied with their life, tend to have lower self-esteem, and less social support from out of one's community compared to adults in other prefectures that underwent smaller amounts of change. Additionally, prefecture and city level collectivistic sociodemographic condition was positively related to social support in one's community. Our study also resonates with the findings on community strength in Japan , in that both types of research focus on societal level resources above and beyond the individual, that in turn sustain residents' health. Future studies need to disentangle the correlates between the socio-demographic condition we used and other societal resources in Japan. --- Limitations of the study In order to disentangle the relationship between change and health one step further, more effective research design would include collecting cross-sectional data measuring a set of health and personality variables from the same, as well as age-diverse participants over time. Because our individual data came from a single shot survey, the results may differ when within-subject data are used to control for participants' past health, as well as past individual level values or personality. By using a large data set involving cohort design we would be able to evaluate the effect of change on the deterioration of health in individuals. In our analytical model we assumed forcefully that individuals had not lived in different prefectures or cities, which is probably not the case. In the joint survey we used in Study 2, we additionally measured individuals' original prefecture defined as the prefecture participants had lived longest before reaching 15 years old. The results we found for the living prefecture did not emerge when participants are grouped into their original prefecture. Even though Japanese do not relocate as often as Americans on average , residential moves strongly affect how individuals construe the self and positive affective experience , regardless of country . It is vital for future research to disentangle the factor of residential moves from what we found regarding prefecture and city sociodemographic conditions, and test if our findings are robust after controlling for individual moves. In doing so, it might also be wise to take into account age at the time of the move as well as the specific combinations of the locations of moves. Further, considering the time span of change in the sociodemographic condition in Japan , one can also argue that Japanese health problems might have had roots long before the 1990. Locating the temporal cause may be extremely difficult without the guide of any theory, but finding an auto correlation between variables , or comparing the same set of variables across different time periods might be an interesting investigation. It must be noted that our analysis contained prefecture scores that showed negligible ICC. Especially, our city level sociodemographic condition showed low reliability, and this may question the reliability of our final outcomes. We note that removing city level factors from the HLM model did not alter our overall findings for other levels. If we were able to find different dimensions that successfully describe cross-regional differences in health, it might override the effect of individual differences we observed in this study. It could also be the case that simply applying national level cultural dimensions to lower level sociodemographic conditions may not be useful to describe health. National level explanations and their lower counterparts may better be kept separate, so that we can theorize and search for more reliable prefecture, or city, or even lower dimensions of subcultures that provide successful contextual explanations that are open to, therefore more suitable to, describing practical problems and considering remedies. Finally, we did not model interactions between different levels in our analysis. That is, there still remains a possibility that the explanatory effects of individual level variables on health are systematically different across regional contexts. Such interactions can be hypothesized when we are able to deduce intricate hypotheses regarding correlational differences across regional as well as temporal contexts. --- SUMMARY In this study, we started from the research question: what are the psychological consequences of economic stagnation accompanying demographic changes away from the traditional way of life? Based on this, we prepared five hypotheses testing negative relationships between prefecture and city level change toward individualistic socio-demographic condition from 1990 to 2010, with five variables of individual health. The results overall suggest marginal to significant weights of change on life satisfaction, self-esteem, and social support out of one's community. We also found positive effects of prefecture or city level JCS on perceived social support in one's community, as well as large weights of interdependent happiness and temperament at the individual level. Future studies should discern further which time period of change or level of socio-demographic condition would truly affect our important life outcomes, using cross-sectional and more representative samples and taking into account the mobile nature of recent Japanese life. --- SUPPLEMENTARY MATERIAL The Supplementary Material for this article can be found online at: http://www.frontiersin.org/journal/10.3389/fpsyg.2014. --- 01221/abstract Conflict of Interest Statement: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Today, countries around the world are caught in the tide of change toward Gesellshaft, or individualistic socio-demographic condition. Recent investigations in Japan have suggested negative impacts of change on emotional and motivational aspects of the Japanese self (Norasakkunkit et al., 2012;Ogihara and Uchida, 2014). Building on previous findings, in Study 1, we measured socio-demographic change toward individualistic societal condition during 1990-2010-two decades marked by great economic recession-at the levels of prefecture and city using archival data. In Study 2, we tested whether Japanese adults' general health, satisfaction with life, self-esteem, and perceived social support were negatively predicted by the change using social survey. Results of hierarchical linear modeling showed small but unique negative effects of the change on several health measures, suggesting that this change had an impact on health, above and beyond individual personality traits, and demographics. Additionally, interdependent happiness, the type of cultural happiness grounded in interdependence of the self (Hitokoto and Uchida, 2014), showed an independent positive relationship with all aspects of health examined. Implications for health studies in changing socio-demographic condition are discussed in the context of Japanese society after economic crisis.

Introduction Psychological distress refers to the symptoms of strain on mental health and includes anxiety, depressive symptoms, and stress [1]. Previous studies have found that demographic, social, and personal factors such as age, gender, marital status, and socioeconomic status have been associated with psychological distress [1][2][3][4]. Psychological distress has been negatively associated with age, but it increases among the elderly, which has been associated with less social support [2]. Among individuals with higher education, higher income, and married individuals, the risk of psychological distress is lower [2]. Women have a higher likelihood of psychological distress than men. Some authors explain these differences through biological, psychological, and social risk factors [5][6][7]. Biological factors involve, e.g., hormonal changes [6], while social risk factors include the role in society and expectations for women and men in a business and family environment as well as the challenges in combining them [5]. Marriage has been found to be associated with better mental well-being in both sexes compared to widowhood and divorce. Becoming widowed has more far-reaching consequences among men than among women [5]. Financial problems are a risk factor for mental disorders [5,8]. It is not just poverty that causes psychological distress but also the stigma associated with receiving public assistance [5,9]. Various studies have found an association between smoking, substance use, and mental health [10][11][12]. Lifestyle factors, such as smoking, heavy alcohol intake, and drug use, are risk factors associated with an increased risk for psychological distress [11,12]. The strength of these associations depends on the substance type, the pattern of their use, and sociodemographic characteristics [10]. Another factor that was shown to mediate the relationship between substance use and psychological distress is the age at which the first use of substances was initiated [13]. It is essential to understand the factors that lead to psychological distress and affect the population, especially the working-age population, to avoid mental, physical, and emotional difficulties and exhaustion associated with illness and inability to work. The inability to work among the working-age population has multiplied individual consequences and numerous social, familial, and economic consequences related to the absence from work. Previous periods of uncertainty and challenges affect not only the person but also society. This is especially evident in times of pandemics or other social unrest, and it could lead to an increased need for interventions for preventing mental health problems, especially for high-risk groups [14]. Our study could help policymakers to implement effective countermeasures and prioritize interventions for high-risk populations. The aim of this study was to examine the association between social characteristics, substance use, and psychological distress in the national representative sample of adults in Serbia. --- Materials and Methods The study was a secondary analysis of the data from the National Survey on Lifestyles of Citizens in Serbia: Substance Abuse and Gambling 2018 [15]. The National Survey on Lifestyles: Substance Abuse and Gambling 2018 in Serbia was a cross-sectional study that included a total of 2000 participants aged 18 to 65 and recruited from the general population in Serbia. The quota non-probabilistic sampling was used as a method for sampling. Two categories were used to determine the stratum: the type of settlement and the region . The households in which the respondents were surveyed were chosen at random, with respect to defined quotas. Any member of the selected household could be interviewed if it corresponded to the quota sample plan given to the interviewer in advance [15]. Trained interviewers conducted data collection via tablet. The face-to-face computerassisted personal interviewing method was applied. The questionnaire was developed for the National Survey on Lifestyles in Serbia: Substances Abuse and Gambling 2018, based on the European Model Questionnaire developed by the European Monitoring Centre for Drugs and Drug Addiction . The questionnaire contained 158 items. The study was conducted between November and December of 2018. The response rate was 90%. Participants gave informed consent after being given a written description of the study process and aims. Individuals excluded from the research were incarcerated individuals, patients in hospitals or therapeutic communities, homeless individuals, and individuals in elderly homes or homes for children, as well as individuals living in illegal settlements. The study was approved by the Ethical Committee of the Republic Institute of Public Health of Serbia 'Dr Milan Jovanovic Batut' No. 6296/1, on 26 October 2021. The study included a total of 13 variables. These variables were age, sex, residence, marital status, education, self-rated health, subjective financial status, anti-anxiety medications in the past 30 days, binge drinking in the past year, smoking status, alcohol consumption, any illicit drug use, and psychological distress. Psychological distress was measured using the Kessler six-item questionnaire. Kessler's six-item questionnaire was used to measure distress based on a question about anxiety and depressive symptoms experienced in the most recent four-week period [16]. Answers were given on a 5-point Likert scale, ranging from never to always . Participants were classified into three categories corresponding to the score on this scale. The first category was no risk of distress , the second category was a moderate risk of distress , and the third category was a high risk of distress [16]. Marital status was defined with the question 'What is your marital status?' . We merged the categories of 'divorced', 'never married', and 'widowed' into 'single'. Self-rated health was defined with the question, 'How would you describe your health?' . We then merged the categories of 'very good' and 'good' into one 'good' and the categories 'poor' and 'very poor' into the category 'poor'. Subjective financial status was defined with the question, 'How would you describe your financial status?' . We merged the categories of 'very good' and 'good' into one 'good' and the categories 'poor' and 'very poor' into the category 'poor'. The use of anti-anxiety medications in the past 30 days was defined with the question, 'Have you used any of the medications for calming down in the past 30 days?' with answers yes/no. Alcohol consumption was defined with the question, 'How often in the past 12 months have you drunk beer, wine, spirits or any other alcoholic drink, even in small quantities, e.g., a glass of beer, wine or spirits?' . Consumers were all those who declared that they had consumed alcohol at least once in the last 12 months. Binge drinking in the past year was defined with the question, 'How often in the past 12 months have you consumed 60 or more grams of alcohol on occasion, which is, e.g., 1.5 L of beer , OR 0.6 L wine OR 0.18 L of spirits drinks) or any other combination?' . We merged the categories of 'every day', '5-6 times a week', '3-4 times a week', '1-2 times a week', '2-3 times a month', 'Once a month', '6-11 times a year', '2-5 times a year', 'once a year' into 'yes' and 'not in the past 12 months' into 'no'. The question, 'Have you ever smoked tobacco?' was used to assess smoking status, and participants were divided into current smokers and non-smokers. The 'ex-smokers' were classified as 'non-smokers'. Any illicit drug use was assessed with the question, 'Have you ever used cannabis , ecstasy, amphetamines, cocaine, heroin and opiates, LSD and hallucinogenic mushrooms, new products that mimic various substances and volatile solvents ?' with possible answers yes/no. We merged the categories of 'cannabis ', 'ecstasy', 'amphetamines', 'cocaine', 'heroin and opiates', 'LSD and hallucinogenic mushrooms', 'new products that mimic various substances', 'volatile solvents ' into 'Any illicit drug'. Statistical analyses were performed using descriptive and analytical statistics. Differences between the categorical variables were examined using the chi-square test. The differences in means in numerical variables were examined using univariate ANOVA. All the variables which were shown significant were entered into two models of the multivari-ate logistic regression analyses. In the first model, the outcome variable was a high risk of psychological distress compared to no distress, and in the second model, the outcome variable was a moderate risk of distress compared to no distress. All statistical analyses were performed using the Statistical Package for Social Sciences 22.0 . --- Results The study included a total of 2000 participants; 945 were male , while 1055 were female; the average age of our participants was 37.83 ± 13.61 years. The prevalence of a high risk of psychological distress was 5.2% , while the prevalence of a moderate risk of psychological distress was 15.2% . There were significant differences between the participants with no risk of psychological distress, with a moderate risk of distress, and with a high risk of psychological distress in average age , sex, residence, education, self-rated health, subjective financial status, use of anti-anxiety medications in the past 30 days, binge drinking in the past year, smoking status, and lifetime illicit drug use. The characteristics of the participants are presented in Table 1. Multivariate logistic regression analysis showed that being male , having poor self-rated health , having poor subjective financial status , binge drinking in the past year and lifetime use of any illicit drug was associated with a higher likelihood for having a high risk of psychological distress. The results of the multivariate logistic regression analysis with a high risk of psychological distress as an outcome variable are presented in Table 2. Multivariate logistic regression analysis showed that being male , having poor , or average self-rated health, having poor subjective financial status , using anti-anxiety medications in the past 30 days , binge drinking in the past year , being a non-smoker , and lifetime use of any illicit drug was associated with having a moderate risk of psychological distress. The results of the multivariate logistic regression analysis with a moderate risk of psychological distress as an outcome variable are presented in Table 3. --- Discussion The aim of this study was to examine the association between social characteristics, substance use, and risk of psychological distress in a national representative sample of adults in Serbia. In this cross-sectional study, we found that several factors are associated with the risk of psychological distress. We have shown that one in six adults in Serbia has a high risk of psychological distress, while one in twenty has a moderate risk. Our analysis showed that being male and perceiving your own financial status as bad, having poor self-rated health, binge drinking in the past year, and lifetime use of any illicit drug were associated with a higher likelihood of having a high risk of psychological distress and point towards a need for a stronger focus on these population subgroups. Earlier studies have shown similar evidence regarding sex differences and psychological distress [5]. Viertio et al. [5] showed that psychological distress is a quite common problem where 11% of women and 8.8% of men in the nationally representative Finnish working population had psychological distress. Moreover, a large survey in the United States reported 15.1% of moderate psychological distress and 3.1% of severe distress over the 2001-2012 period [5]. The authors stated that with the different rating scales and cut-off scores used in previous research, the given prevalence figures of psychological distress are not correctly correlative between countries [5]. Matud et al. also showed that women scored higher than men in psychological distress [2]. Previous studies have likewise found that financial difficulties constitute a notable risk factor for psychological distress [9,17,18]. One previous study found that being a man with a low household income was associated with psychological distress, which is consistent with findings from our research [18]. Through different mechanisms, poor material living conditions may affect mental health, including poor social networks and restricted access to health care services [18]. When comparing the risk for experiencing common mental disorders among sexes, men and women seem different when classified by income category; in all other categories except the lowest one, women's risk is higher than men's risk, but financial difficulties in covering household costs seem to have equally harmful effects on mental health in both [5]. In line with previous research, binge drinking and the use of any illicit drug were associated with more psychological distress [11,12,19]. In a population-based study of adolescents, they found that alcohol use and all specific combinations of substance use were significantly associated with medium and high psychological distress. Moreover, they noted that according to their analyses, the associations between substance use and psychological distress differed across regions. In particular, substance use was not associated with psychological distress in the Eastern Mediterranean region [19]. In previous studies on the Serbian population, psychological distress was associated with smoking status [10] and problem gambling as outcome variables [20], while there was no association between psychological distress and binge drinking [21]. Additionally, sex-specific role expectations and norms, such as associating drinking alcohol with masculinity, may be related to the male preponderance of drinking [22,23]. While alcohol could be used to reduce anxiousness in some individuals, heavy alcohol consumption leads to anxiety, distress, and depression, which in turn can lead to higher levels of alcohol consumption, leaving the person caught in a dangerous circle [21]. A cross-sectional study of nationally representative samples of the United States National Survey on Drug Use and Health, individuals age 12+, showed that adults with substance use disorders who smoke cigarettes experience more than twice serious psychological distress compared to those without substance use disorder who do not smoke cigarettes [24]. These results add further evidence for the co-treatment of substance use disorders and mental health problems. In some studies, psychological distress was associated with feelings of loneliness, symptoms of insomnia and consequential anxiety, and even suicidality [19,25]. However, many previously conducted studies on the association between psychological distress and substance use examined only specific populations, commonly adolescents and people with substance use disorders, or examined only the use of one specific substance, such as marijuana [13,19,26]. According to the information provided by the National Institute of Mental Health online in the Substance Use and Co-Occurring Mental Disorders section, individuals with substance abuse disorders may also have other mental health disorders. Individuals with mental health disorders may also fight substance use. While pointing out that individuals can have a substance use disorder and a mental disorder, this does not mean one caused the other. The studies so far demonstrate three probable modalities that could describe the co-existence mechanism of these problems [27]. One previous study investigated the genetic correlation, pleiotropy, and causal relationships between substance use and psychiatric disorder, suggesting that common risk factors such as specific genes and environmental factors may be risk factors that contribute to both substance abuse and mental disorders [28,29]. Many individuals with additional mental health conditions such as anxiety and depression may use substances as self-medication which can make symptoms worse over time and can lead to severe mental illness and cause substance disorders abuse [30]. Vice versa, substance use and substance use disorder can cause the appearance of other mental disorders due to changes in brain structures and functions [27,28]. The main strength of the present study is the high response rate. Additionally, our study is the first analysis to assess the association of social characteristics, substance use, and psychological distress in the adult population in Serbia on a large nationally representative sample of the working-age population. To the best of our knowledge, no study has yet been committed to the topic of the association between social factors and psychological distress either in Serbia or in the Western Balkans using data from a nationally representative sample, while most studies conducted in New Zealand, Australia, and the United States examined only distress as one of the independent variables in relation to other outcome variables [31]. The main limitation of our study is the cross-sectional design, which does not allow us to determine the direction or causality of the associations. Furthermore, data were obtained using a self-report questionnaire; therefore, we did not obtain detailed information, e.g., about mental disorders. Self-reporting bias, such as social desirability and recall bias, could affect the results. Other limitations related to individuals excluded from the research were incarcerated individuals, patients in hospitals or therapeutic communities, homeless individuals, individuals in elderly homes or homes for children, and individuals living in illegal settlements. Our findings do not apply to these individuals, and some settings may show a higher frequency of substance and alcohol use than the sample from the population used in this study as well as a higher frequency of psychological distress. A limitation might be the participants' lack of desire to share information with the researchers. A possible limitation could be that some participants may have given socially desirable answers to some questions regarding substance abuse. --- Conclusions One in six adults in Serbia has a high risk of psychological distress, while one in twenty has a moderate risk. Our analysis showed that being male and perceiving one's own financial status as bad, having poor self-rated health, binge drinking in the past year, and lifetime use of any illicit drug were associated with a higher likelihood of having a high risk of psychological distress and point toward a need for a stronger focus on these population subgroups. Therefore, this study contributes to reducing the gap in knowledge about the association of social characteristics, substance use, and psychological distress in the adult population. The findings of our study can help direct future research in developing and implementing an integrative program for people suffering from psychological distress and people with alcohol-and drug-related problems. More intensive cooperation is needed between the experts dealing with different aspects of substance and alcohol use and experts dealing with preventive activities. --- Data Availability Statement: Data can be made available upon request. ---

This study examined the association between social characteristics, substance use, and psychological distress in a national representative sample of adults in Serbia. It was a secondary analysis of the National Survey on Lifestyles in Serbia: Substance Abuse and Gambling 2018. The study included a total of 2000 participants aged 18 to 65 from the general population in Serbia. Psychological distress was examined using the Kessler 6 questionnaire. There were a total of 945 male participants (47.3%) and 1055 (52.8%) female participants. The average age was 37.83 ± 13.61 years. The prevalence of a high risk of psychological distress was 5.2% (103/2000), while the prevalence of moderate risk of psychological distress was 15.2% (303/2000). Multivariate logistic regression analysis showed that being male, having poor self-rated health, having poor subjective financial status, binge drinking in the past year, and lifetime use of any illicit drug were associated with a higher likelihood of having a high risk of psychological distress. One in six adults in Serbia has a high risk of psychological distress, while one in twenty has a moderate risk. The findings of this study urge targeted actions to protect and improve the health of people in psychological distress and drug and alcohol users.

formal care and their intersection, and applicable across care settings. Drawing on existing critiques of research on informal-formal care intersections , we examine care relationships using the "convoy of care" model . Past research and conceptual models, such as Cantor's hierarchical compensatory model, the substitution model , and Litwak's task specificity model, address care complexity, but treat formal and informal care as separate spheres or overlook surrounding social, economic, and structural contexts . Kemp et al.'s model extends Kahn and Antonucci's , "Convoy Model of Social Relations," which conceptualizes individuals as embedded in "convoys" of close personal relationships that evolve over time and are "vehicles through which social support is distributed or exchanged" . The modified model incorporates formal caregivers and suggests that long-term care recipients are situated within care convoys defined as "the evolving community or collection of individuals who may or may not have close personal connections to the recipient or one another, but who provide care…" . Multilevel contexts influence care, including policies and resources at the federal, state, and community levels and those factors operating within care settings, networks, and relationships . Assisted living, for example, is regulated at the state level and is a setting where most care is provided by unlicensed care aides . Home health and hospice services are a growing presence . Assisted living's social approach to care relies on resident self-care and informal caregiver contributions, which are vital to meeting residents' needs . Typically, family members and friends provide socioemotional support, assistance with instrumental activities of daily living , and care oversight . Assisted living research identifies informal care networks with a primary person and those with shared responsibilities . Little else is known about how informal caregivers organize themselves over time in the context of formal care , but research reveals some general informal care patterns within families. Studies show, for example, that families range from individualistic to collectivist in their approach to caregiving and that high within-family consensus about care recipient behaviors influences family dynamics and perceptions of burden . Research also shows caregiving responsibilities within sibling networks can be unevenly distributed by employment and family status, proximity, and gender and highlights distinct caregiving approaches by gender . Corcoran's research among individuals caring for a family member with dementia demonstrates distinct caregiving styles: facilitating; balancing; advocating; and directing. This typology incorporates the dynamic and complex nature of caregiving through an examination of intentions and strategies, but not how care is experienced by multiple caregivers within care networks. Existing research provides important insights into care, but no known research involves entire care convoys studied systematically over time. Seeking to advance knowledge of care relationships and processes, our goal is to obtain in-depth understanding of residents' care convoys in assisted living. We seek to: understand care convoy patterns, including their structure and function; and identify how and why convoys vary and with what resident and caregiver outcomes. --- Design and Methods We present analysis of data collected for the qualitative longitudinal study, "Convoys of Care: Developing Collaborative Care Partnerships in Assisted Living." The overall goal was to learn how to support informal care and care convoys in assisted living in ways that promote residents' ability to age in place with optimal resident and caregiver quality of life. An in-depth consideration of our methods appears elsewhere . The study was guided by principles of grounded theory methods, which involves a constant comparison approach whereby data collection, hypothesis generation, and analysis occur simultaneously . Building cumulatively on previous grounded theory research, the Convoy of Care model provided "sensitizing concepts" and a "place to start, not end" for our study. For instance, the model conceptualizes care as a process influenced by multilevel factors and calls for a holistic and longitudinal approach to studying care. We report on data collected between September 2013 and October 2015 in four assisted living communities purposively selected to maximize variation in size, location, ownership, resident characteristics, fee structure, and availability of a dementia care unit . [Georgia State University]'s Institutional Review Board approved the study. For anonymity, we use pseudonyms for sites and participants. --- Settings and Sample Our first site, Hillside, family-owned and rural, was licensed for 11 residents, all White. Garden House had a separate DCU and was family-owned, in a small town, and licensed for 54 residents; the majority were White. Feld House, foundation-run and licensed for 46 residents, almost all Jewish, was suburban and had an extra care area, but no DCU. Oakridge Manor, licensed for 92 residents, all African American, was corporately owned and had a DCU. Prior to entering sites, we distributed letters to residents, families, and staff and posted flyers with researcher names and photos. Across sites, we recruited 28 focal residents purposively selected to provide information-rich cases that reflected variation in personal characteristics , functional status, and health conditions, factors expected to influence convoy structure, function, and adequacy. Residents ranged in age from 58 to 96 years, with a median of 85. The majorities were women , White , and widowed and had some college or a college degree . Formal and informal caregivers were selected based on their involvement in and knowledge of resident care. We enrolled as many individuals as possible, resulting in 114 convoy participants, including 5 assisted living executive directors and 24 staff, 20 external care workers, and 65 informal caregivers. All executive directors were women between 38 and 59 years. Most had some college education. Staff included nursing or resident relations personnel , care aides , activity personnel , and maintenance and transportation workers . They were between 24 and 72 years. The majority were women with some college. Over half were African American. External care workers included medical doctors , hospice workers , nurses , therapists , and a private care aide . Three-quarters were women; over half were White. All had at least some college. Informal caregivers were residents' family and friends, including spouses , children , siblings , grandchildren , other kin , and friends and volunteers . Most were women and White ; 79% had a college degree, 66% were married, and 46% were retired or unemployed. --- Data Collection Investigator-led teams of trained gerontology and sociology researchers collected data. During the first month, we began participant observation and conducted in-depth interviews with executive directors to learn about the community. Next, we began recruiting focal residents and convoy members; convoy member recruitment was ongoing over the 2 years. We used National Institutes of Health guidelines to assess residents' informed consent capacity. For those unable to consent, we used proxy consent from legally authorized representatives and assent procedures . All interviews occurred at a time and place of participants' choosing and, except for a sibling pair and three married couples, were conducted one-on-one. Interviews ranged from 30 to 330 min, with a mean of 98; resident interviews lasted longer than other interviews, with a mean of 168 min. In-depth interviews with residents typically occurred over multiple sittings and addressed their lives, relationships, past and present care needs and arrangements, including self-care, and experiences. Convoy member interviews inquired about relationships with the resident, care roles, responsibilities, and experiences. Site visits occurred one to three times weekly, depending on home size. To capture the full range of care activities, we varied visits by time and day of the week. Participant observation took place in residents' rooms, with permission, and in common areas and during mealtimes and activities. We made 809 visits and logged 2,225 observation hours, all recorded in fieldnotes. After completing formal interviews with focal residents and staff, researchers followed up weekly, collecting data prospectively. We attempted twice-monthly follow-up with at least one informal caregiver per convoy to assess changes in care needs and arrangements. Facility record review provided data about diagnoses, medications, care plans, service agreements, doctor visits and orders, and adverse events. --- Analysis We used NVivo 10 to store, manage, and facilitate coding and analysis of all qualitative data. Initially, we coded data with broad concepts driven by research aims . We used intercoder comparison queries to achieve consistency. As data collection and analysis occurred simultaneously, all 18 researchers engaged in data collection, coding, and analytic discussions. The higher-order analysis described in the following paragraph was conducted by the authors. An indepth account of our analytic processes appears elsewhere . Following Corbin and Strauss , we used a threestage coding process. First, we examined the data for concepts based on our questions about convoy patterns through open coding. Initial codes included, for example, "primary informal caregiver," "shared responsibility," "collaboration," "leadership," and "consensus." Through axial coding, we related initial and other categories using a paradigm denoting "conditions," "actions-interactions," and "outcomes" . We created analysis charts that noted, for example, connections between residents' receipt of timely and appropriate care and staff, external worker, informal caregiver, and resident influences and convoy properties. Finally, we refined and integrated concepts into a conceptual scheme through selective coding, organized around our core category, "maneuvering together, apart, and at odds." Evoking images of navigation in our data, the core category links subcategories in our explanatory scheme to characterize the dynamic and variable patterns and processes associated with care convoys. --- Results --- Maneuvering Together, Apart, and at Odds Represented in Figure 1, our core category-maneuvering together, apart, and at odds-reflects the variable ways convoy members navigated the care landscape and negotiated care needs, roles, relationships, and arrangements in an ongoing way and during times of crises. Figure 1 presents the care process as organized, but as our data show, the realities of care were not always so orderly. Care convoys varied in structure, function, and adequacy across and within convoys over time. Each had a trajectory unique in direction and duration, marked by stability and change related to resident and convoy members' involvement, and punctuated by the timing and sequencing of events, transitions, and turning points in the care process. As Figure 1 shows, the ways convoys maneuvered were influenced by convoy structure and function, including leadership effectiveness and responsiveness of convoy members, and levels of consensus, collaboration, and communication within convoys, all of which were shaped by the intersection of regulatory, community, assisted living setting, convoy, and individual factors. How convoys maneuvered influenced residents' ability to age in place and care quality and their own and caregivers' quality of life. The three ways of maneuvering-together, apart, and at odds-align with three types of care networks identified in the data: cohesive, fragmented, and discordant. We discuss each below in the section, "Convoy Types", but first we explain care convoy composition and care roles, as both influenced how convoys maneuvered while navigating the care context and negotiating care processes and relationships. --- Care Convoy Composition and Care Roles The 28 focal resident care convoys were made up of varying, and often fluctuating, numbers of informal and formal members who provided a range of care activities, also changeable, over time. Figure 2 shows the types of caregivers identified across convoys. Residents, as the center of their convoys, were part of the care process. Although children participated in 21 of the 28 convoys, 4 focal residents had no children and 3 had uninvolved children. Other family caregivers included spouses, siblings, grandchildren, nieces, nephews, and daughters and sons-in-law. Non-kin convoy members were friends, neighbors, ministers, fraternity and sorority members, volunteers, and fellow residents. In what follows we examined the contributions of each convoy member type to enhance understanding of how care convoys operate in assisted living and with what outcomes over time. --- Resident involvement The self-care ability of focal residents varied widely, determined by their changing health status, care needs, functional and cognitive ability, care preferences, support from caregivers, access to assistive devices, and the structure of physical environment. The majority of focal residents needed help with three or more ADLs and IADLs and with medications . Most reported their health as "good" or "fair"; 82% used an assistive device, including a walker , wheelchair , or both ; 33% had cognitive impairment. Although most performed some self-care, residents ranged in abilities, from Naomi, a Hillside resident with substantial cognitive impairment who could carry out none, to Ethel at Oakridge Manor, who, as the only focal resident who led her own convoy, assumed primary responsibility for care provision, oversight, and coordination. --- Informal care Informal caregivers were integral members of almost all convoys, and, based on our interviews and observations, were knowledgeable about or directly involved in resident care on an ongoing basis, for respite, or during crises. Although 65 were formally interviewed, data collection yielded information on 210 informal caregivers. As with resident self-care, informal support varied and typically included most IADL and occasional ADL assistance, care monitoring and coordination, and socioemotional support. Executive directors characterized informal involvement as a "spectrum" from daily to minimal. Garden House's owner noted: "All families are different. One fellow's just got his daughter and she's pretty much the primary caregiver. Some folks have multiple children that visit. Generally, some kids live out of town and they visit when they can." Informal convoys varied in size and configuration. We distinguished between convoys with a primary caregiver, who provided all or most informal care, and those with shared responsibilities. Sixteen focal residents had convoys with a primary caregiver, 12 were children , one spouse, one sibling, one niece, and one friend. Most lived locally and had other convoy members who provided periodic regular support or intermittent respite. In 12 convoys, informal responsibilities were shared. Shared convoys tended to be larger and more diverse than those with a primary caregiver and included the largest with 26 informal members ; half had nontraditional caregivers . Generally, shared convoys, partly because of size, were more likely fraught with challenges for residents and convoy members, especially assisted living staff and administrators. Sharing of responsibilities, though, could lessen caregiver burden. --- Formal care Assisted living staff furnished the typical services of ADL and medication assistance, monitoring and oversight, housekeeping, nutrition, and activity programing. Three residences offered transportation to medical appointments for a fee; one provided shopping services. All four had a "point person" who supervised and coordinated resident care. Oakridge Manor's care director explained the importance of this position, "It's a very difficult decision to move into assisted living, so helping [residents and families] navigate and maneuver through assisted living, coordinating with third party providers, so whether it's hospice or home health, knowing when it's time to coordinate, [my] job entails that." Complex health care called for convoy members capable of understanding and managing multiple care components. Formal caregivers from the external community provided care, on-and off-site. Privately paid care aides, used infrequently, largely because of cost, enhanced aging in place and quality of care and life. Health care providers, including physicians, nurses, dentists, podiatrists, x-ray technicians, and various home health and hospice professionals, visited all homes. For 15 focal residents, across all sites, virtually all health care occurred in-house. A nurse practitioner who visited Feld explained, "For some people, we truly are now their primary care provider." Eleven focal residents received almost all care off-site; two had a mixture. Off-site care required greater effort arranging appointments and transportation, tasks typically shared by residents, informal caregivers, and assisted living staff. The majority of focal residents were hospitalized during data collection, 12 multiple times; 4 were in rehabilitation facilities and 20 had home health services. Garden House's director described a common pattern following a resident's hospitalization, "[Angela] ended up in a rehab unit. . . .When she comes back, they'll have home health, physical therapy, and probably occupational therapy." Hospice services were used by five focal residents and across settings. At Hillside, most residents, including all three focal residents, received hospice. --- Convoy Trajectories: Stability and Change Care convoys were marked by stability and change in membership and in type and level of care, resulting in unique convoy and care trajectories. Residents' health changes triggered temporary or permanent modifications in self-care and the nature, amount, and sources of support utilized. Some transitions were anticipated ; some were not . Changes in informal caregivers' lives initiated temporary or permanent transitions in convoy structure, function, and adequacy. Four informal caregivers died during the study, creating notable voids in residents' lives. Travel, employment, health, and other family responsibilities were frequent with effects reverberating within convoys. As noted, changes in residents' health status also caused shifts in formal convoy members and often temporary relocations to other care settings. All convoys experienced change. --- Convoy Types Care roles and structures provide an important entry point for understanding care, but do not account fully for convoy function and outcomes. Our analysis identified components consequential to the function and adequacy of care networks over time: levels of consensus surrounding care plans and goals; degree of collaboration to achieve goals; leadership effectiveness; communication quality; and responsiveness. We classified convoys as cohesive, fragmented, or discordant based on the pattern that dominated each care network over the 2-year study period. Yet, reflecting the reality, dynamism, and complexity of care arrangements and relationships, types were not mutually exclusive. For example, some convoys were cohesive for the majority of time, but had periodic or "situational" fragmentation or discordance resulting from health or convoy transitions and led to a temporary lack of coordination or disagreement about care needs, goals, and plans. --- Cohesive convoys We categorized 22 of the 28 convoys as cohesive. In cohesive convoys, the most supportive for residents and caregivers, care partners had clearly defined care goals, unified efforts, and maneuvered the care process together. Identifying and achieving goals required agreement, collaboration, and effective communication among convoy members. Setting goals involved a formal or informal member initiating dialogue. Garden House's care coordinator noted, "My new thing . . . is getting residents to think about their goals for their time here. Is it to live as long as possible or is it to live with the best quality of life with the time you have left?" Cohesive convoys possessed well-defined informal leadership, responsive members, and clear directives for health and financial matters. Hillside's owner described a common pattern: In cohesive convoys, collaboration and cooperation were successful, mainly through ongoing, open, and effective communication. Hillside's owner observed about families: "For the most part, especially if they're here a lot, they see what we see, and so we're always on the same page." Naomi's daughter, who shared responsibility with her siblings in a cohesive convoy, said, "We are 100 percent in agreement on all of mother's care." Naomi remained at Hillside, despite significant decline, in part because of shared and continuous family involvement and convoy cohesiveness. The majority of cohesive convoys had a primary informal caregiver who assumed the leadership role. Although this configuration typically fostered cohesiveness and good outcomes for residents and caregivers, other factors could intervene. For example, Carl, whose mother had high physical and emotional need, had minimal support from his wife and one out-of-state brother. Initially Carl often managed daily visits with minimal burden, but a job change with travel decreased his involvement and his mother's satisfaction. Shared responsibility offered more options, opinions, and potential for conflict, but Feld's Resident Services Director emphasized that if roles were "clear cut then it's easy, but if it's not decided amongst them then it's harder." When convoy members were mutually "responsive" to requests and cohesive, shared convoys functioned effectively and had good outcomes with residents feeling supported and able to age in place and caregivers experiencing support and satisfaction with their roles. In Ethel's informal convoy, the largest with 26 members, her leadership enhanced cohesiveness. --- Fragmented convoys Fragmented convoys had some consensus about care goals but minimal communication, collaboration, or cooperation among care partners. We categorized 4 of the 28 convoys as fragmented. One had a primary caregiver; in three, informal responsibilities were shared among multiple members. Because fragmented convoys typically lacked informal leadership, the assisted living "point person" often assumed care coordination. For Ernest, a resident at Oakridge Manor whose informal care was shared among a niece who lived out of state and 14 non-kin members, the resident director helped coordinate medical appointments. Convoy member responsiveness and resident involvement also could help overcome informal leadership deficits in fragmented convoys. With well-established roles, fragmented convoys generally could meet residents' needs, including a Garden House resident, Fred, whose children "all help one way or another." Yet, because they lacked close relationships, his children did not coordinate or communicate regularly. Illness, hospitalization or a change in caregiver availability could strain these potentially fragile convoys, often impacting care quality. Health crises though sometimes led to temporary collaboration, as illustrated by Feld resident Susan, whose fragmented convoy consisted of her three children who interacted only on holidays and had unilateral care roles. With Susan's hospitalization for pneumonia, communication increased, as one daughter explained, "We are in a lot of communication when she has a crisis. . . . We are always filling each other in on what the latest is." Occasionally care was overlooked as happened in Ernest's fragmented convoy where one person ordered medication and another paid the bills. A staff member noted issues with "the pharmacy holding the medication because they were waiting on payments." --- Discordant convoys Discordant convoys, 2 of 28, lacked agreement about care goals, including appropriate roles and behaviors. Convoy leadership, particularly among informal caregivers, was either absent, unclear, or contested. Disagreement occurred within informal networks and with assisted living staff or other caregivers. Relative to cohesive and fragmented, predominately discordant convoys typically had the most negative outcomes for residents and caregivers. Hillside's owner described feuding siblings: [If the] sibling who is not the POA is not agreeing to the schedule, then the other person can just take them, because they're not wanting the other one to see them. . . It's not our place by law to tell the other person to leave if there's not any order against them being here. The causes of discord included family dysfunction, off-time caregiving, and an inability or unwillingness to balance care with competing demands. Predominately discordant convoys were the least supportive of residents' ability to age in place and frequently led to frustration and dissatisfaction among residents and caregivers. The three convoy types we identified were not mutually exclusive or constant. For instance, two convoys at Garden House experienced marked change in type during the study. Described in the Case Examples section, one predominately cohesive convoy with a primary caregiver experienced a temporary period of discord. And, noted earlier, one fragmented, shared convoy became cohesive during the residents' health crisis. Another fragmented, shared convoy temporarily transitioned to discordant when a resident's friend became a romantic interest and assumed an increased care role, a transition unwelcomed by some family members. This discord was problematic for the resident and his convoy members. The fluidity of types reflects the stability and change that defined convoy trajectories. --- Case Examples We provide two examples to illustrate convoy function, adequacy, stability, and change. These cases contain elements of all three types, demonstrate accompanying resident and caregiver outcomes, and highlight key factors that shape how convoys maneuver through care processes over time. Illustrated in Figure 3, Alice, a Garden House resident, widowed and in her 90s, had a predominately cohesive convoy with a temporary/situational episode of discord and a trajectory with numerous health and convoy changes. Physically frail with cognitive impairment, Alice used a walker, and later a wheelchair, and received staff assistance with all ADLs, some IADLs, medication management, and oversight. The nurse hired by the family to oversee her health care complimented staff saying, "I like the fact that they do get her out of bed and still keep her involved." Alice's local daughter, Pam, a health care professional, was the primary informal caregiver. Her participation included health care management, monitoring, visiting, and outings. Pam said: "I don't have any family or anyone else in the area who comes and visits her. It's about me. My husband comes sometimes on Sundays with me, and we take her out to eat. . . ." Although she downplayed her husband's contributions, he visited regularly and often took Alice out. Pam's out-of-state sister, Caroline, provided money management and visited. Caroline said, "I coordinate with Pam. What I try to do is give her a break." About decision making she said, "Pam would talk to me about it, but I would absolutely defer to her recommendation both because of her experience with geriatric populations and because she has healthcare power of attorney." Generally staff described Alice's support system as "great." Alice and her daughters were "happy" with care at Garden House. Pam noted, "They're pretty good to communicate with me when they notice a change." Alice's decline prompted staff to recommend the DCU. The daughters disagreed and "fought" the move for months, creating additional care work and discord. The care coordinator characterized negotiation as "a tough, tough battle," explaining, "Alice needs toileting because if she's left to do that alone there's a lot of clean up involved . . .That was a very hard sell because the staff protected that for so long and wanted to protect her dignity so they didn't tell her family what was going on." Over time, Pam's employment changes reduced visits and Alice's "mobility challenges" ended outings. With continued decline, convoy members and the home's owner collaborated with the goal of honoring Alice's request to "Stay here the rest of my life." Alice was placed on hospice and during her last week received around-the-clock care. Hospice kept her "comfortable" and worked with staff and her daughters to help them understand Alice's progression "along that end-of-life spectrum." Alice's cohesive convoy enabled her to age in place with quality care, which enhanced caregiver satisfaction, all positive outcomes. In contrast, Deborah, who moved to Feld House at age 62, 8 years after developing early-onset Alzheimer's disease, had a convoy with shared informal responsibilities that was fragmented with limited coordination and escalated to discord. Deborah had memory, speech, vision, and mobility deficits and high blood pressure and cholesterol, anxiety, and depression. As Figure 4 illustrates, Deborah performed limited self-care; staff provided help and cueing with all ADLs, medication management, and oversight. Deborah, divorced, had two daughters in their twenties, Ruth and Nancy, and a son, Keith, in his thirties, who were her health care decision makers. Sisters, Diane and Sheila, though, were Deborah's most involved informal caregivers. According to Sheila, it was "a balancing act" with Diane visiting weekly and handling most IADL tasks. The children visited "maybe once a month if that" and filled in for "urgent things." Deborah's boyfriend, Lester, in his 80s, visited when in town for medical appointments and sometimes stayed overnight in Deborah's room. They talked daily by phone, with help from staff. Convoy members' lives were complicated by jobs and health issues. Their relationships were rocky, then and in past. Sheila termed the family "fractured" and "dysfunctional" stating the kids had "trouble growing up" and lacked knowledge of "how to interact in a loving family." Communication was emergency-driven, usually by e-mail and text; occasional face-to-face meetings addressed future care in the face of "dwindling" finances. Sheila noted, "Here, you've got disparate people with disparate lives and goals and things to do. . . .I feel like Diane and I are like the Jiminy Cricket on Pinocchio's shoulder, with the kids, 'This is what she needs'. . . .We're trying our best to cobble together something that's functional for Deborah." Communication with staff was similarly lacking. Services coordinator, Alexis, described Deborah's family as "very difficult to get a hold of" and their fragmented roles and unresponsiveness challenging: "If I need something financially, it's Diane. . .if we need something medically, it's the kids. So like she just had a couple issues recently and you leave messages and they call back but not necessarily as quickly as we might need. . .and they don't communicate to us [about] what we can do to make that easier." Diane welcomed staff support, but noted: "there is still so much to navigate. . . .it would be nice for people to point the way." Deborah's decline also was emotionally draining. Keith explained, "On one hand, you want to celebrate that your mother is still there. On the other hand, all you see is how much you have lost. This dichotomy has become a dark cloud hanging over our entire family." Deborah's cognitive decline led to relocation to the extra-care wing. Increasingly aggressive behavior triggered temporary stabilizations in a psychiatric hospital and, finally, discharge. According to Alexis, Deborah "totally destroyed" her room and "physically attacked" three residents. The family remained "very uncooperative, very unhelpful." That night ". . . nobody answered except for Keith. . .it was like 2 in the morning, and he was like, 'What do you want me to do?'" To Alexis, families like Deborah's "can definitely get in the way. . .Keith does not believe that mom is capable of doing the things that we said she was doing. We see her every day; we are not making this up. . . . So it's communication." Ultimately, Deborah's discordant convoy failed to meet her care needs and support aging in place and left convoy members frustrated and burdened. --- Discussion We depart from conventional approaches to studying care by emphasizing intersections of formal and informal care and focusing on entire care convoys studied qualitatively, in-depth, and over time. The process of "maneuvering together, apart, and at odds," with the accompanying model and convoy typology, illustrate the complexities and dynamics of care experiences, patterns, and influential factors, previously undocumented in the care literature, especially in assisted living and over time. In what follows, we discuss our findings and their implications for care research and practice. Findings confirm that care recipients are care partners. Residents participated in self-care and care management based on ability, willingness, and extent of convoy support. Existing work documents the importance of self-care for autonomy and independence, which are threatened by safety and convenience in some assisted living settings . Optimizing care recipients' involvement requires greater caregiver time, patience, and willingness and has implications for well-being and quality of life and must be prioritized in any care setting. Doing so requires communication practices that include care recipients in their own care decisions and activities insofar as possible. Our work extends Ball et al.'s distinction between primary and shared informal caregiving by incorporating variation in the structure and dynamic of care convoys and including multiple members. Primary informal caregivers sometimes overlooked the support they had from others. For example, Pam minimized her husband's contributions, which enhanced Alice's care and Pam's respite opportunities. Family members in assisted living report greater burden than those in nursing homes, likely owing to greater involvement , and are apt to benefit from respite. Reinforcing the need for respite and creating opportunities for meaningful caregiver support through policy and practice can promote resident and caregiver quality of life and care. Findings shows that shared informal networks have the capacity to distribute responsibility across individuals and enhance access to informal assistance, especially during crises. As in prior research on family caregiving , challenges arose in the absence of clearly defined roles or consensus, both consequential to care outcomes regardless of convoy size and composition. Network size was a complicating factor in our data and noted in Gaugler, Reese, & Sauld pilot work. Our data also show that although convoy factors were highly influential, resident-, caregiver-, facility-, and communitylevel factors, could have equal and interactive importance. Convoys in our study demonstrated the advantages of care planning and goal-setting. Most states require service planning based on periodic assessment of residents' health and functional status , but our work shows that goals are not always established or agreed upon within and across care networks, underscoring the need for effective communication. We recommend ongoing discussions that include care recipients and informal and formal convoy members and developing care plans and roles that support established goals. Case management may be beneficial, particularly when care recipients and informal caregivers are vulnerable or need help navigating the landscape. Some of this responsibility was assumed by assisted living staff, especially care directors. Zimmerman and colleagues point to the potential value of social workers despite lack of standard regulations governing social services in assisted living. Quantitative assessments indicate interpersonal-conflict between staff and family members in assisted living are rare, but "suggest room for improvement" . Fragmentation and discord within convoys, including among and between informal and formal caregivers, were not uncommon even within cohesive convoys, underscoring the potential value of social services in long-term care settings. Our data show the potentially negative outcomes for caregivers and recipients when there is within-convoy disagreement over time. Inclusion beyond a primary person provides a more comprehensive understanding of care than previously existed. As illustrated, parent care frequently is shared among siblings , and network changes are common, implying the need to shift caregiving research from "individual" and "cross-sectional approaches to dynamic and systemic analyses" . Findings illuminate the contributions of nontraditional informal caregivers who lack normative obligations governing spouses or children. These convoys require further scholarly attention as many individuals now and in future will rely on nontraditional helpers. Data affirm the consequential nature of informal care for individuals' quality of life and care and ability to age in place. Formal providers compensated to varying degrees for lack of informal leadership and responsiveness, but this arrangement was not sustainable, especially with limited resident involvement. For example, although Deborah's shared informal convoy included traditional members, none assumed responsibility and collaboration was absent. Complicating the dysfunctional family context, caregiving occurred "off-time" for her children, who were unable or unwilling to respond. The care context, including care recipients' needs and caregivers' capacity to provide care, is highly consequential and renders certain convoys and hence, care recipients, more vulnerable and less supported relative to others. Our work confirms the value of considering informal-formal care intersections . Assisted living staff provided most hands-on care and essential emotional support. This low-paid workforce is in need of greater recognition and remuneration . Escalating resident frailty in assisted living means a growing number of formal care partners and calls into question how best to deliver health care . We provide insight into how care is accomplished, yet this area warrants closer examination as the industry struggles between social and medical care models . Family and friends were consequential to resident care, particularly during decline or crises. As others note, informal caregivers frequently are advocates and important decisionmakers. Sharpp and Young found, for instance, that in absence of licensed nurses and training, "strong family involvement was essential" to preventing unnecessary emergency room transfers for assisted living residents with dementia. Engaged informal caregivers and convoy consensus, communication, and collaboration differentiated Alice's ability to age in place and Deborah's discharge. Care convoys were unique, yet all had trajectories shaped by care relationships and contexts and multiple multilevel factors. Due to the complexity of the research design , we are able to identify more complex models of care than existing research . All convoys experienced stability and change, but the ability to successfully navigate the latter was not universal. Our case examples also highlight key factors affecting how convoys maneuvered in assisted living and point to those factors that facilitate and constrain quality of life and care. Analysis confirms certain factors identified in the Convoy of Care Model . At the regulatory level, Medicare reimbursement for rehabilitation, home health, and hospice services and state assisted living regulations shaped care options and access and affected aging in place. The size and location of a home's surrounding community influenced options for health care, staffing, and volunteers. Equally influential were assisted living residence factors, including aging in place philosophy and policies, care planning, staffing practices, training, turnover, and resources. Among caregivers, attitudes, beliefs, strategies, knowledge, resources, and availability affected care quality and quantity. Finally, residents' cognitive and physical function, communication strategies, material and social resources, and relationships affected convoy structure, function, and outcomes. --- Limitations and Future Directions Although we believe our research is innovative, it has limitations. First, we formally interviewed multiple informal convoy members and gathered data directly or indirectly for most members, but were unable to formally interview everyone. Certain convoy data are more complete than others. Second, we selected residences that represent the range found in the United States, but the present analysis only uses data from four sites. Future analysis of data from additional sites will build on and extend our present findings. Next, the majority of residents and informal caregivers in our sample had some college or a college degree. Our previous research shows that education, an indicator of social location and access to resources, shapes care options, care relationships, and care experiences . Our ongoing data collection involves participants with rather limited resources and will expand the range of care experiences represented in the present sample. Finally, in order to delve deeply and understand the complexities of convoys, our sample size is limited and we rely on qualitative data and methods. Future research might consider using larger samples, mixed-methods, and interventions targeting communication, consensus, and collaboration to strengthen convoys. Despite limitations, our design shows the value of a comprehensive approach to studying care relationships and illuminates the path to holistic understandings of care and creating collaborative care partnerships in assisted living and other long-term care settings. --- --- Conflict of Interest We have no conflict of interest to declare.

Objectives: Frail and disabled individuals such as assisted living residents are embedded in "care convoys" comprised of paid and unpaid caregivers. We sought to learn how care convoys are configured and function in assisted living and understand how and why they vary and with what resident and caregiver outcomes. Method: We analyzed data from a qualitative study involving formal in-depth interviews, participant observation and informal interviewing, and record review. We prospectively studied 28 residents and 114 care convoy members drawn from four diverse assisted living communities over 2 years. Results: Care convoys involved family and friends who operated individually or shared responsibility, assisted living staff, and multiple external care workers. Residents and convoy members engaged in processes of "maneuvering together, apart, and at odds" as they negotiated the care landscape routinely and during health crises. Based on consensus levels, and the quality of collaboration and communication, we identified three main convoy types: cohesive, fragmented, and discordant. Discussion: Care convoys clearly shape care experiences and outcomes. Identifying strategies for establishing effective communication and collaboration practices and promoting convoy member consensus, particularly over time, is essential to the creation and maintenance of successful and supportive care partnerships.

Introduction Around the world, population ageing creates challenges for human and financial resources, individual health and quality of life, as well as equity and well-being in society [1]. Now more than ever, as the COVID-19 pandemic increases isolation and ageism [2], the importance of social interactions and participation is widely recognised but this presents new challenges in terms of security and roles [3][4][5], At the beginning of the pandemic, one in three older Canadians reported concerns about maintaining social ties [6]. For most older Canadians , opportunities for social interactions were and still are very limited. Based on a scoping review of the definitions of social participation in older adults, which included articles up to 2009, social participation could be defined as a person's involvement in activities that provide interaction with others in society or the community [7]. As a health determinant, enhanced social participation helps older adults to be active and, in response to concerns about population ageing [8] that inspired public policies , is a key proposal of the World Health Organisation . Following the UK Minister for Loneliness' appointment, several countries in Europe considered officialising efforts to combat loneliness [10], against which social participation has a known protective effect [11]. Social participation is also associated with a reduced risk of mortality [12][13][14] and morbidity [15], greater functional independence [16], greater satisfaction with life [17], and shorter hospital stays [18]. When social participation is optimal [19], older adults might have a sense of purpose and contribution, and their engagement benefits society as well as themselves [20]. For example, volunteering encourages values such as altruism and also fosters the feeling of being valued and respected in one's community, which in turn increases resilience in response to stress [21] and can lead to positive mental health outcomes, including less loneliness [22]. Social participation should be seen as encompassing involvement not only in non-profit and public organisations, including volunteering, but also in many other aspects such as social and leisure activities, and informal support between families and neighbours. By participating in society according to their needs, desires and capacities, older adults reduce their risk of social exclusion, which is a 'process through which individuals become disengaged from mainstream society, depriving people of the rights, resources and services available to the majority' [23:681], and increases as they grow older. Lack of access to material resources such as income and housing or to healthcare restricts social participation [24] and increases inequalities, which could be attributable to the combination of population ageing, ongoing economic instability and situations of vulnerability [25]. Many factors, such as being over 80 years of age, having a low income [26], belonging to a racial, ethnic or linguistic minority, presenting one or more disabilities, or identifying as belonging to a sexual or gender minority [27], can interact and increase the risk of marginalisation and social exclusion [25]. It is thus essential to promote older populations' social participation using processes that enable their inclusion. Such processes include giving them a voice, providing meaningful opportunities and improving access to proximity resources, while respecting their rights [24,28], fighting systemic ageism [29], and reviewing policies on participation in ageing [30,31]. Promotion of social participation should consider a variety of life experiences, foster structural and cultural access to participatory settings, and offer spaces supporting new identities, including ageing with disabilities. To expand the study of social participation and better understand, encourage and value older adults' contribution to society, it is important to adopt a consensual and current definition of the concept. Although a previous review contained a content analysis of definitions and proposed a synthesis [7], a qualitative study presented results according to dimensions [32], and a concept analysis was carried out [33], many researchers still define this concept in their own way [34], which only exacerbates the confusion surrounding the meaning of social participation. Moreover, a recent study of the current generation of older adults reported a lack of alignment between their aspirations, concerns and participation opportunities, especially for women [35]. As witnesses to or being involved in societal advances in social, civil and political rights, this generation is diversified and generally reaches older age in better health and living active lives, searching for freedom, wishing to start new life projects, and advocating for self-determination and a greater citizen presence [36]. They also report needing spaces to contribute and do their activities, regardless of their health and without worrying about being productive and useful [37,38]. Today's ageing generation wants to participate and be recognised and active, not necessarily in roles valued by society or liberal policies based on contributing and volunteering, but in ways that reflect their own interests and capacities. Empowered older adults can describe their own experiences and reality [39]. Moreover, in keeping with approaches involving personalisation [40] and reablement [41], older adults should be involved in revisiting the definition of social participation, i.e. given a voice in the conceptual work. This paper provides an updated inventory and synthesis of definitions of social participation in older adults. Based on a critical review by content experts and knowledge users, a consensual definition is proposed. --- Methods Following PRISMA guidelines [42], including collaboration between researchers and knowledge users [43] and validation by a documentalist , the methodological framework for scoping studies [44,45] was used to synthesise current knowledge concerning definitions of social participation in older adults. Papers retrieved were published between February 2009 and March 2020 in four databases with relevant keywords , and websites were also searched. Conceptual definitions were extracted from each paper by MLT and ÉL and content-analysed using seven predetermined interrogative pronouns: who, how, what, where, with whom, when and why [7]. These pronouns identified critical dimensions of the concept of social participation [46]. Themes emerging from this condensation were deductively organised and renamed according to the Human Development Model-Disability Creation Process , a model of human development and disability [47] similar to the International Classification of Functioning, Disability and Health [48] in terms of approaches, objectives, and elements of the models' components [49]. The HDM-DCP illustrates interactions between personal and environmental factors, and participation. Three of the researchers independently performed the content analysis with an inter-rater agreement before discussion of 96.9% ; it was then validated by the principal investigator . All discrepancies were resolved through discussion between at least two members of the interdisciplinary research team, with final decisions approved by the principal investigator . To enrich and validate the results of this first step, as is often done in scoping studies [43], the dimensions identified with the seven interrogative pronouns provided the starting point for a 90-minute workshop conducted by the principal investigator . This workshop aimed to reach a consensus on key elements of the definition of social participation and identify participants' perceptions of related challenges and concerns. The workshop involved 32 content experts and knowledge users, i.e. 11 researchers, 8 partners, 7 collaborators and 6 students from an interdisciplinary emerging partnership on older adults' social participation [50,51]. While workshop participants were mainly academics who conducted research on social participation, partners and collaborators came from community organisations working directly with or representing older adults . All dimensions identified were discussed, not just the commonest. The workshop began with testimony concerning social participation from three older adults and, to validate the main ideas, finished with a synthesis of the proposal. The workshop was audiotaped and a research professional took notes, mainly on a clipboard. The workshop also included a 15-minute PowerPoint presentation summarising preliminary results, followed by a 60-minute discussion on which key elements to retain. During this discussion, older adults primarily shared their views while some of the researchers briefly raised points from their own studies to stimulate debate. The notes and audiotape were considered throughout the content analysis of the definitions and when proposing a consensual definition. By revisiting the definitions three times, i.e. synthesis and workshop, and triangulating these perspectives, the authors of the present paper corroborated the analysis and a consensus on the definition was reached. This work was supported by a Social Sciences and Humanities Research Council emerging partnership [#890-2012-0034]. --- Results Of the 2,326 papers retrieved through electronic searches, almost half were duplicates and 936 did not meet the inclusion criteria based on titles and abstracts . Of the remaining 314, more than two fifths were excluded since they did not provide a definition of social participation; nearly half were eliminated because they referred to another source. Ultimately, 54 original definitions , 15 of which were added because of extended search strategies , were extracted and content-analysed . Year of publication of the papers containing an original definition ranged from 1987 to 2020. Almost three quarters were published after 2010, with the most productive year being 2019 . A majority of first authors were from North America and Europe , principally working in healthcare and social services and gerontology or geriatrics , with nearly one-tenth from rehabilitation . Only a limited number of the definitions came from the psychology, sociology, education and social work literature. Most papers specifically concerned older adults and used the term social participation or social engagement . A majority reported empirical results, mostly from quantitative cross-sectional or longitudinal studies. One-fifth of the papers were more conceptual, with the majority from reviews. --- Definitions According to the content analysis based on the seven interrogative pronouns, dimensions related to how and what were found in most definitions . Dimensions concerning who and where and with whom were present in Ability to take advantage of opportunities for social interaction; nursing home residents' involvement in the social and recreational life of the facility Social participation [54:415] Individuals' levels of participation in both social and civic affairs Civic engagement [55:236] Ways in which citizens participate in the life of a community in order to improve conditions for to others or to help shape the community's future Social participation [56:283] Person takes part in the activities of formal and informal groups as well as other activities in society Social engagement [57:331] The extent to which individuals participate in a broad array of social roles, relationships and activities Social participation [58:1811] Ability to participate in work and education Social participation [59:5] Collective activities that individuals may be involved in as part of their everyday lives. This might include: being a member of a community group, a tenant's association or a trade union; supporting the local hospice by volunteering; and running a study group on behalf of a faith organisation Social engagement [60:1189] A psychological thought process and a conscious behaviour that shapes all forms of social relationships and by which social ties and social networks are derived. This includes both relationships that are a source of social support and those that are less supportive Social engagement Formal social engagements and social interactions with other friends and relatives Social engagement [72:549] Participation in activities that involve interactions between or among people, capturing a broader array of social interactions and intensity of interaction that may contribute to greater social integration Community participation [73:772] Active involvement in activities that are intrinsically social and either occur outside the home or are part of a nondomestic role Social participation [74:7] Interaction that older adults have with other members of their community and the extent that the community itself makes this interaction possible Social participation [75:2] Person's involvement in social activities Social engagement [76:939] Contacts or connections between individuals that include some element of socio-emotional exchange, that is, flows of interactive, utilitarian and affective elements Social participation [77:657] Formal [. . .] voluntary commitment to community organisations on a regular basis Social participation [78:82] Engagement in daily social activities Social engagement [79:642] Participation in social activities and socialisation with others Social participation [80:1] Participation in civic groups that an individual can join, regardless of occupation or family situation [83:334] Carrying out meaningful social roles through activities embedded within social relationships Social participation [11:25] Attending external activities, such as social clubs or volunteering Social participation [84:976] Accomplishing an attempted life habit without difficulty Social participation [85:555] Person's engagement in social groups Social participation [86:133] People's involvement in social activities Community participation [87:1161] Involvement in local economic, political, cultural and voluntary activities Social participation [88:2] Form of social interaction that includes activities with friends, family and/or other individuals Social engagement [89:1062] Participation in social activities, such as community events, volunteerism or providing support to older people Social participation [90:801] Respondent's social group involvement Community integration [91:526] Community involvement and interaction with social networks Social participation [92:3] Involvement in society had occurred [. . .] The aspects were: public meeting, attending a club, participating in society or other meetings, etc. Social engagement [93:156] Interaction with neighbours and participation in social activities including attending religious services, social clubs/organisation meetings, sports/cultural activities and civic/political organisations Social participation [94:317] Both aggressive participation and passive participation in social interactions Social engagement [95:187] Taking part in events, meetings and activities within a local community Social participation [96:1959] Two categories •-Formal: participation through membership of an organised association •-Informal: day-to-day activities initiated by older people themselves, without an organisation Social participation [97:6] Various activities in which the older adults participate in their neighbourhood, including five styles: volunteer works, self-management and mutual assistance activities, lectures and reports, recreational and sports activities, and interest groups Social participation [33:68] Conscious and active engagement in outdoor social activities leading to interacting and sharing resources with other people in the community, and the person has a personal satisfaction resulting from that engagement Social participation [98] Participating in activities of a social nature, i.e. nurturing meaningful relationships, being part of a community, and participating in group, volunteer or paid work activities Social engagement [99:2] To engage in both individual and society-level activities. Also called social participation or social involvement, forms the basis of social relationships or participation in a community and provides a sense of belonging, social identity, and fulfilment Social involvement [100:2] •-Informal: relationships with people from one's social network, such as family and friends, and focuses on useful interactions that entail provision of support in which adults are needed and beneficial •-Formal: activity in formal organisations, such as volunteering Civic engagement [101:39] Psychological attentiveness to social and political issues Civic participation [101:39] Action [on social and political issues]; behavioural in nature; activities conducted individually or within a group or organisation ; civic activities may primarily aim to help others, solve a community problem or produce common good, with no manifest political intention , or may explicitly seek to influence political outcomes almost half the definitions. Dimensions related to when and why were found less often . No definitions specifically targeted instrumental activities or responsibilities , current and satisfaction of needs or survival , but one definition newly focused on educating . Most definitions focused on people involved in activities providing interactions with others in society or the community . Following is a detailed description of the dimensions identified in the definitions for each interrogative pronoun. Who-Although one paper in five defined social participation from an individual perspective , most definitions took a population perspective . How-Social participation was mostly defined as involvement, i.e. taking part, and included participation, connection, contribution or integration of the person. While engagement referred to a stronger commitment and was mostly emphasised by public health, performance focused on actions and ability to take advantage of opportunities or participate. What-Social interactions and activities were mainly found in the definitions, and generally came from the field of 1, 5, 15, 17, 20, 25, 30, 36, 41, 49 10 How 2. Involvement 1-6, 8, 11, 14-18, 22, 23, 25, 29-32, 34, 37, 38, 40-48, 50, 51, 54 16, 20, 21, 28, 36, 49, 51, 54 8 3. Performance 2, 7, 13, 19, 35, 54 6 What 4. Activities 1, 5, 6, 8, 10, 14-16, 19, 22, 23, 30, 33, 34, 35, 39, 46-48, 50, 52, 54 22 50 4.1 Social activities 1, 3, 8, 11, 12, 14, 19, 25, 29, 37, 40, 42, 44, 46, 48-51, 54 8, 14, 18, 19, 27, 35, 38, 40, 48, 50, 52 11 4.1.2 Community activities 3, 8, 14, 19, 34, 40, 42-44, 46, 48, 53, 54 13 4.2 Recreational activities 12, 18, 44, 48 4 4.3 Daily activities 28, 47, 51 3 4.4 Instrumental activities - 5. Social roles 1, 5, 6, 17, 20, 21, 27, 32, 33, 47, 52 11 5.1 Responsibilities - 6. Social interactions 2, 6, 9, 10, 11-15, 17, 18, 21, 22, 24, 26, 29, 33, 39, 42, 44, 45, 50-52 1, 4, 5, 11-13, 15, 17, 19, 23, 38, 41, 43, 46, 48, 49-52, 54 gerontology and geriatrics. Papers referred to life situations or different kind of activities: other, external, individual, collective, various, formal, informal, paid or voluntary. For one definition [62], social engagement specifically involves formal social relations, as opposed to informal ones that include ties to family and friends. --- Scoping study of definitions of social participation Where-Social participation was more commonly defined as happening in the community or society, especially in the public health literature, but also occurred in organisations, mostly related to gerontology and geriatrics. No definition specifically mentioned virtual participation. With whom-Definitions mentioned that social participation involves family, friends, neighbours or other individuals, especially in gerontology and geriatrics, and also groups or associations, mostly in the public health field. Five definitions described how others or groups are involved, namely by offering social and emotional support, having a reciprocal relationship, or making the interaction possible. When-According to two definitions, social participation takes place regularly. Why-Finally, and mainly from the gerontology literature, approximately one definition in four mentioned that social participation involves development, mainly personal but also social , or meaningfulness, such as helping others. Meaningfulness is based on older adults' interests and what gives them a sense of belonging or fulfilment or contributes to their identity. Only one definition considered social participation as including support from others or being educated. --- Co-construction of an interdisciplinary consensual definition According to content experts and knowledge users and based on previous results and testimony from three older adults, social participation can be defined as the action of being involved in community life, socially or politically and structured by the environment, which places can be shared, and which are significant. Participating socially is a conscious, free choice, not an obligation, and it takes various evolving but significant forms according to available time. Social participation is highly personalised, i.e. based on individual priorities, motivations, and interests, and involves social interactions and relationships with others. While it can be achieved for oneself and simultaneously for community well-being and development, social participation gives life meaning. Based on the literature review and to better represent older adults, social participation can be defined as a person's involvement in activities providing interactions with others in community life and in important shared spaces , evolving according to available time and resources , and based on the societal context and what individuals want and is meaningful to them . --- Discussion This paper provides an updated inventory and synthesis of 55 definitions of social participation in older adults, enriched by a discussion with content experts and knowledge users. Based on these findings, social participation can be defined as a person's involvement in activities providing interactions with others in community life and in important shared spaces, evolving according to available time and resources, and based on the societal context and what individuals want and is meaningful to them. A consensual definition is important in order to better communicate, develop or select measuring instruments, intervene, develop policy or analyse research results [7]. Although it shares similarities with the previous synthesis [7], this new definition emphasises the where, when and why. One conceptual analysis of social participation also emphasised the importance of community-based activities, interpersonal interactions, sharing of resources, active participation and individual satisfaction [33]. The why of the current definition is also globally related to all dimensions of social participation identified by Raymond and colleagues [32], which were developing significant relationships, enjoying pleasant group activities, engaging in a collective project, assisting and supporting each other, sharing knowledge, and being empowered in decisions concerning themselves. These dimensions provide clear examples of what older adults want and what contributes to their development and is meaningful to some of them. However, this does not constitute a norm and may differ from societal expectations, an important point that cannot be overemphasised. Linked to the key elements of the mobilisation process [32], the dimensions also highlight the involvement and even the engagement of older adults. Compared to involvement, engagement indicates a contribution that can be more demanding and sustained [7]; this appeared more often in recent definitions. Finally, the number of original definitions increased compared to the previous synthesis. This may be attributable, not just to the longer period, but also to the greater importance of this concept in the last decade or to the persistent lack of agreement. Given the importance of active ageing and the contribution of older adults to society, socioeconomic and personal development, benefits for older adults and society, selfactualisation and goal attainment. Also emphasising the why, the influence of some international health policies must not reinforce normative standards or society's expectations and stigmatise older adults who choose not to be or cannot be involved in some social activities. Older adults can participate socially without being involved in an organisation, such as by doing activities with their grandchildren or helping neighbours, family, friends or others, or even during everyday activities such as shopping or going to the hairdresser. While ageing, personal and environmental resources that are mobilised to participate socially can change [47] and might necessitate assistance from community organisations and health and social professionals [102]. To encompass a broader perspective of social participation, professionals who work with older adults might also help them to use relevant resources, and promote their autonomy and connectedness with the community [98]. Social participation must be recognised as a personal choice and human right, and health policies should include actions to facilitate involvement in activities or interactions meaningful to people, especially older adults with disabilities or insufficient personal or environmental resources. Compared to the previous synthesis [7], recent definitions referred less often to where social participation takes place. Based on the workshop, community is important, as is community life, which highlights the importance of social interactions and activities that take place in the neighbourhood and other public spaces. During the COVID-19 pandemic and despite sanitary measures, using public spaces generated anxiety in older adults and most people worried about infecting family members or friends through social interactions [103], which greatly increased the risk of being socially isolated [104]. To foster physical distancing and restrict propagation of the virus, the size and ventilation of these public spaces and building materials used must be rethought. Friendliness and safety of neighbourhoods are also important factors associated with social participation that have been emphasised not only in policies but also in empirical studies synthesised in a review [105]. Sometimes the environment itself can cause social exclusion [25], like stairs for people with limited mobility. With advancing age, life space can be even more restricted and the neighbourhood becomes a central element in the social participation of older adults [106,107], including interactions between neighbours [108]. Time was also mentioned less often in this new synthesis, yet evolution of the concept over time is an important dimension, which was reported in this study's workshop and documented in previous studies [109][110][111][112][113][114][115]. For instance, --- Scoping study of definitions of social participation when interviewed about their neighbourhood participation, New Zealanders aged 85 and over reported holding onto everyday life as participating and being concerned about maintaining their capacities while ageing [116]. Evolution can occur not just in individuals but also between generations [35], justifying the need to revisit the concept over time, especially when important societal changes occur, such as increased use of social media or a pandemic. The workshop also raised the issue of the time available to participate socially, a dimension linked to 'optimal' participation, being the fit between an individual's reality governing how social activities are done and expectations about them [19]. Although the why and, more specifically, reference to meaningfulness were added after the workshop, fewer definitions in the recent literature included this dimension compared to the previous synthesis [7], a finding that may concern the baby boomer generation which values freedom, new life projects, self-determination and greater citizen presence [36]. In addition, older adults may feel they contribute to society and fulfil a role when they help others, such as by volunteering, babysitting or caring for family members [117]. The importance of meaningful activities and purposeful life has been highlighted, especially in the occupational sciences [118], and there are emerging interventions that empower older adults to develop their own routines fostering their health and making life more fulfilling. For example, Lifestyle Redesign [119], a preventive occupational therapy intervention has been shown to improve health, be cost-effective [120] and has been adapted to many contexts, including Quebec, Canada [121,122]. While it is important to prevent loneliness and isolation, social participation should not only be a way for older adults to stay active, it should also increase their well-being, feeling of being valued and sense of purpose. Finally, rather than being an obligatory contribution to society, including economic activities, meaningfulness should have a more central place in health policies, according to the content experts and knowledge users in this study. Thus, to improve health promotion, these policies should increase their scope to specifically include informal and meaningful participation, which would encompass a broader spectrum of the ageing population. --- Strengths and limitations Expanding upon a previous synthesis and using a rigorous, innovative procedure, a methodological framework for scoping studies and content analysis using interrogative pronouns, this study presents an in-depth review of many original definitions of social participation found in various multidisciplinary databases. This procedure involved at least two people analysing the content of definitions and a workshop with content experts and knowledge users from an emerging interdisciplinary partnership on social participation. Among its limitations, this study did not include the concepts of participation, societal participation, handicap, disability, meaningful activities and occupation, which generated too many unrelated results, although some papers using these concepts might have been relevant. Moreover, retrieving original definitions was occasionally challenging as papers sometimes define the concept implicitly or mainly for operationalisation purposes. Finally, although they might reflect an evolution in the definitions or different perspectives in the group, opinions from two groups of authors [85,90,101] might be overrepresented in the analysis as two original definitions were extracted for each group. --- Conclusion This scoping study provides an updated inventory and synthesis of definitions of social participation in older adults enriched by a critical review involving content experts and knowledge users. Although the literature mostly defined social participation as people's involvement in activities providing interactions with others in society or the community, content experts and knowledge users emphasised the importance of community life and shared spaces. Moreover, social participation should be seen as evolving with available time and resources and based on what individuals want and is meaningful to them [123] and the societal context. As the pandemic clearly showed, social participation and interactions are essential for people's well-being. To enable community organisations, healthcare providers and decision-makers to encourage social participation, on the ground and in policies, a deep understanding of its conceptualisation is needed as it evolves with virtual communications and respect for social distancing. In their studies, researchers must provide a definition of social participation and choose a measuring instrument accordingly. Future studies should involve older adults, family members and professionals working with them and examine how social participation is operationalised and measured. To make it easier to compare research results, the aim should be to achieve a consensus regarding a single definition and a measuring instrument. --- Declaration of Conflict of

Background: considering the importance of social participation for quality of life and active ageing in older adults, it is an important target of social and health professionals' interventions. A previous review of definitions of social participation in older adults included articles up to 2009; new publications and changes in the social context (e.g. social media and the COVID-19 pandemic) justify continuing this work. Objective: this paper provides an updated inventory and synthesis of definitions of social participation in older adults. Based on a critical review by content experts and knowledge users, a consensual definition is proposed. Methods: using a scoping study framework, four databases (MEDLINE, CINAHL, AgeLine, PsycInfo) were searched with relevant keywords. Fifty-four new definitions were identified. Using content analysis, definitions were deconstructed as a function of who, how, what, where, with whom, when, and why dimensions. Results: social participation definitions mostly focused on people's involvement in activities providing interactions with others in society or the community. According to this new synthesis and input from content experts and knowledge users, social participation can be defined as a person's involvement in activities providing interactions with others in community life and in important shared spaces, evolving according to available time and resources, and based on the societal context and what individuals want and is meaningful to them. Conclusion: a single definition may facilitate the study of active ageing and the contribution of older adults to society, socioeconomic and personal development, benefits for older adults and society, self-actualisation and goal attainment.

Introduction Infertility represents a major reproductive health issue with substantial clinical, humanistic, and economic burdens, alongside demographic repercussions. It is defined as a disease of the female or male reproductive system characterized by the failure of achieving clinical pregnancy after engaging in regular unprotected sexual intercourse for 12 months or more [1,2]. With the staggering global lifetime prevalence reaching approximately 17.6% of the adult population, based on World Health Organization estimates for 2022, infertility may have a profound and devastating impact on contemporary society and affected individuals [2]. The magnitude of this public health concern, hindering the attainment of several United Nations Sustainable Development Goals , underscores the need for a comprehensive and multifaceted agenda targeting policy formulation and advocacy, research efforts, and educational activities concomitantly with the provision of reliable, accessible, and equitable fertility care services [3]. Addressing the infertility in a responsible and coordinated manner is of paramount importance for fostering sexual and reproductive health and rights and, subsequently, the overall physical and mental wellbeing. The intricate and heterogeneous pathogenic landscape of infertility challenges both its epidemiologic and causative analysis. Although the interaction between partners determines the fecundity, it is estimated that pure or combined male-factor-associated infertility is present in approximately 50% of all the couples experiencing undesired childlessness [4]. The etiology of male infertility encompasses a broad spectrum of pre-testicular causes, testicular disorders, and post-testicular conditions. The underlying mechanisms may be traced to disrupted spermatogenesis, gonadal and extragonadal endocrine disorders, congenital or acquired anatomical defects, functional urogenital anomalies, immunological and genetic-related causes, sexual dysfunction, infections, certain chronic illnesses, environmental exposures, and lifestyle determinants [5,6]. Nevertheless, in 30-40% of primary testicular failure subjects, the etiology remains elusive, and these cases are referred to as idiopathic male infertility [7]. Despite reasonable limitations regarding the assessment of the overall spermatozoal fertilizing capacity, intraindividual variability in relevant parameters over the course of time, and analytical standardization issues, conventional semen analysis remains fundamental and often the most informative component of the infertility evaluation in men [8]. Nevertheless, quantitative and qualitative semen parameters complying with reference values do not necessarily equate to normal fertility, as some men may have latent health impairments or fertility disturbances. Conversely, abnormal semen analysis results do not unavoidably indicate infertility [9]. All men facing conception difficulties should receive a comprehensive medical assessment to identify and address any modifiable risk factors compromising their reproductive potential. The implementation of a structured multidisciplinary clinical care algorithm featuring reproductive endocrinologists, andrologists, and general urologists supports the streamlining of the diagnostic process and treatment planning, eventually resulting in better procedure coordination and enhanced patient care. By leveraging the expertise of these specialists, a collaborative practice model fostering a holistic and personalized approach establishes a dynamic platform for a seamless and well-orchestrated exchange of knowledge, insights, and resources, thereby facilitating the pursuit of targeted and tailored interventions, leading to superior patient outcomes. Furthermore, accumulating scientific evidence suggest that infertile men may have increased susceptibility to cardiovascular diseases, certain oncopathologies, and phycho-emotional disorders, underscoring the importance of appropriate screening and counseling [10,11]. The inability to meet personal desires and public expectations of male procreation is often recognized as a threat to the traditional perception of masculinity and may be related to social stigma and significant impacts on the quality of life of men and their partners [12]. In men who regard fatherhood as an important element of their male identity, the inability to become biological parents may trigger profound psychological distress featuring an array of negative emotions, including the feelings of shame, guilt, and inadequacy. By acknowledging the fertility issue and engaging in activities related to treatment, some men are forced to deconstruct and re-frame the embodied notions of their manhood [13]. Regardless of the rising prevalence trends in male factor infertility, this topic largely remains taboo, at least partially due to the societal norms discouraging men from disclosing their struggles and openly discussing their vulnerabilities. Furthermore, there is a notable gender imbalance in the current literature on infertility, as most studies have focused on the female position, thus often leaving the male perspective overlooked or underestimated [14,15]. Hence, it is essential to expand the breadth and depth of the scientific knowledge base regarding the QoL of infertile men to gain a deeper insight into their needs and to inform the development of effective interventions aimed at enhancing their overall health and welfare [16]. The objective of this study was to investigate the QoL and emotional distress of men undergoing infertility treatment in Serbia, using a multi-dimensional approach featuring validated self-report questionnaires, physical measurements, and medical records, to provide a holistic perspective of the complex interplay between psychological and physical factors in men's experience of infertility. Particular emphasis was placed on the exploration of the impact of the treatment duration on the QoL and psycho-emotional disturbances, as well as the sequence of relationships between these constructs. --- Materials and Methods --- Study Design and Participants This observational, cross-sectional study recruited a sample of patients attending the Clinic of Urology, University Clinical Center of Serbia for infertility treatment, from January to May 2018. The recruitment protocol included four consecutive stages: identifying potential participants and screening against the predefined criteria, approaching the selected men and proposing their inclusion in the current research project, providing all the relevant information regarding the purpose of the study, responsible entities, and a detailed description of anticipated activities, and specifying the protection procedures applied for ensuring personal data privacy and confidentiality, prior to finally seeking ethically valid and scientifically appropriate consent. In order to limit participants' burden and avoid additional clinical appointments that may compromise the overall recruitment rate, both data and sample collection were organized within the individual's standard outpatient care schedule. All the recruitment activities were performed by trained healthcare professionals, i.e., 4 responsible urologists serving as members of the core research team. Acknowledging the possibility of intentional and/or unintentional bias introduced by so-called "gatekeepers" [17,18], the selection protocol and conditions were clearly articulated and formally approved by the internal Clinic's Professional Board, and the initial screening stage was performed concomitantly by two independent researchers. Eligible participants were adult men of 18 years and older willing to join the study, experiencing at least one year of primary or secondary male-factor-associated infertility confirmed by a specialist in accordance with The European Association of Urology Guidelines on Male Infertility [19], with an absence of cognitive disability precluding the capacity to provide responses to study questionnaires independently and accurately. The exclusion criteria were as follows: compromising mental illnesses or severe functional impairments, a history of alcohol and/or drug abuse that may distort the validity of the obtained results, present psychiatric disorders requiring treatment, and limited language/communication capacities. A total of 118 men undergoing infertility treatment were approached over the course of the recruitment process and screened against the predefined eligibility criteria. Among suitable subjects, 102 voluntarily agreed to participate in the study. Nevertheless, due to failure to adhere to the research protocol and provide all the required data prior to study completion, 4 men were disqualified and thus excluded from further analysis. Furthermore, 2 decided to withdraw their consent, yielding a final sample of 96 male individuals and an overall response rate of 81.36%. --- Ethics Statement This non-incentivized study was conducted in accordance with the ethical principles and standards of medical research involving human subjects expressed in the Declaration of Helsinki. The protocol was approved by the Ethics Committee, Faculty of Medicine, University of Belgrade . All research participants provided written informed consent for data collection, semen sample provision, and the subsequent analysis. --- Data Collection --- General and Medical History Data Participants' sociodemographic, lifestyle, and medical data were collected with a purposefully devised questionnaire in a standardized manner via structured face-to-face interviews conducted by trained healthcare professionals. By maintaining a professional and objective attitude, the interviewers aimed to establish an atmosphere of trust, thus ensuring that each subject was treated respectfully and with dignity. General information included age, residential region, education, occupation, prior paternity, and self-perceived socioeconomic status. The compilation and presentation of the highest attained level of formal education were performed in compliance with the well-established International Standard Classification of Education reference framework [20], whereas the patients' professional profile was indicated based on categories proposed by The International Classification of Occupations [21]. Furthermore, the questionnaire addressed relevant lifestyle determinants and diverse environmental factors associated with an adverse impact on male fertility [22]. Comprehensive medical data, including present acute and chronic conditions, past medical and surgical history, and family history, were retrieved from personal health records. --- Anthropometric Assessment The anthropometric assessment was performed in a clinical setting during the physical examination by skilled medical staff. Participants' body weight in light clothing and without footwear was measured using an electronic platform scale with tarring capacity calibrated to 0.1 kg . Height was recorded with an accuracy of 0.1 cm with a mobile stadiometer . Body Mass Index was calculated as a ratio of weight and standing height squared . Based on BMI, subjects were allocated to normal weight , overweight , and obese categories [23]. --- Physical Activity Evaluation Patients' physical activity estimates were based on the internationally acknowledged and broadly applied self-administered International Physical Activity Questionnaire-Short Form [24]. The instrument referring to the 7-day recall period captures vigorous and moderate-intensity physical activities, walking, and sitting, all undertaken across a wide-ranging set of domains, including occupation-related activities, transportation, domestic/household chores, and leisure time. Featuring seven short response items, the IPAQ-SF imposes minimal respondents' burden, thus implying negligible survey fatigue-induced bias [25]. Following the questionnaire scoring manual and the Compendium of Physical Activities coding scheme [26], the activity scores were converted into metabolic equivalents in minutes per week. Such a measure, introduced to facilitate and promote the inter-study comparability of coded physical activity indices, is presented in both absolute values , as well as in the form of 3-level categorical scores . The sedentary period was not included in energy expenditure calculations, but is presented as a separate informative entity. The threshold for excessive sitting was set on 540 min per day [27]. --- Evaluation of Psycho-Emotional Disturbance The participants' level of psycho-emotional distress was evaluated with the Depression Anxiety Stress Scales -42 questionnaire [28]. This survey tool represents the tripartite construct characterized by a low positive effect, anhedonia, life devaluation, avolition, inertia, and hopelessness specific to depression, physiological hyperarousal, apprehension, and general distress pertinent to anxiety, and persistent irritability, impatience, agitation, nervous tension, and chronic non-specific arousal corresponding to stress [29]. A substantial research corpus featuring DASS-42 provides robust evidential verification of the questionnaire's good psychometric properties, reliability, and validity in both community and clinical populations. DASS-42 encompasses forty-two self-report items divided into three subscales referring to distinguishable, yet moderately inter-correlated, negative emotional symptom clusters [30]. The instrument's reference period is the past week, and each item is rated on a 4-point Likert-type severity/frequency scale ranging from 0 to 3. Domainspecific scores are summed for the respective scales, with higher scores indicating more pronounced distress and a higher prevalence of the syndrome-related symptoms. Given that DASS-42 is based on the underlying assumption that emotional disorders intrinsically display a continuum of severity, this tool provides quantitative rather than categorical measures. Without the ambition to assign respondents to discrete diagnostic entities postulated by the conventional morbid taxonomic classificatory frameworks, DASS-42 scoring and interpretation guidelines propose cut-off values for percentile scores defining mild /moderate /severe /extremely severe labeled categories for each subscale. --- Health-Related Quality of Life Assessment The 36-Item Short Form Survey was employed for the assessment of the health-related quality of life [31]. Accommodating the diversity of major dimensions and operational definitions of health and acknowledging the potential and utility of wellconstructed standardized short-form assessment tools, SF-36 is a patient-reported generic multi-faceted eight-scale instrument. The comprehensive conceptual structure of the questionnaire encompasses the following spectrum of health domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health. Following the introductory tool familiarization and filling out instructions, the questionnaire was self-administered in the presence of research staff. No proxies were allowed by the study protocol, and the completion time averaged 10-15 min. In order to minimize the desirability bias and interviewer-related confounding effects, researchers adhered to a standardized script aiming to communicate with respondents in a neutral, non-suggestive non-judgmental manner. The computational analysis of the SF-36 was performed as a multi-step procedure resulting in eight subscale-specific numerical scores. First, the pre-defined Likert-type values were re-coded and linearly transformed per the weighted percentage-based scoring key. Subsequently, items pertaining to the respective health domain were averaged to create eight summary measures ranging from 0 to 100, whereby lower values represent less favorable outcomes and more intensely perceived disability. --- Semen Examination Semen processing and analysis were performed by an accredited laboratory following standardized procedures compliant with the internationally acknowledged World Health Organization manual [32]. Ejaculates were obtained through masturbation after 3-7 days of sexual abstinence in a private room on clinical premises into a specialized sterile graduated wide-mouthed test-vessel made of spermatozoa non-toxic material. Men were provided with a detailed information sheet and precise spoken instructions concerning the appropriate protocol for semen sample collection. In order to prevent the adverse impact of sample exposure to temperature fluctuations and ensure a proper assessment of liquefaction, the specimen containers were placed in an incubator preset at 37 • C within 5 min after the collection. Routine macroscopic evaluation, volume determination, and preparation of dilutions and smears for the assessment of quantifiable features and spermatozoa qualitative attributes were performed in the following 30-60 min. Patients were allocated to appropriate categories based on semen parameters. The lower reference limits for the semen volume, sperm concentration, total spermatozoa motility, and progressive motility were 1.5 mL, 15 × 10 6 spermatozoa per mL of ejaculate, 40%, and 32%, respectively. Patients presenting with a reduced sperm concentration were further classified into 3 subgroups: severe , moderate , and mild oligozoospermia. Sperm motility findings not meeting the defined criteria were considered asthenozoospermia. Patients with less than 4% of morphologically normal spermatozoa forms according to the Papanicolaou staining procedure and an observation with brightfield optics in oil immersion at 1000× magnification were diagnosed with teratozoospermia. The estimated presence of leukocytes determined by the peroxidase activity assay in concentrations exceeding the consensus-based threshold value of 1.0 × 10 6 per mL of ejaculate was labeled as pyospermia. --- Statistical Analysis Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 28.0. , and open-source JASP software, version 0.17.2 [33]. Continuous data were summarized with the appropriate measures of the central tendency complemented by measures of dispersion , whereas categorical data were presented in absolute numbers and frequencies. The normality of the variable distribution was explored with the Kolmogorov-Smirnov test. Differences between sample subgroups were assessed using the Mann-Whitney U test or the Chi-square test, in accordance with the variable type. Spearman's rank correlation was employed to evaluate the strength and direction of associations between DASS-42 and SF-36 scale scores. In conjunction with the conventional frequentist statistical approach, Bayesian inference was adopted with an aim to enhance the effect of the robustness estimation and credibility of the conclusions. Therefore, alongside frequentist statistical metrics, the Bayes factor is reported as a quantitative indicator of the relative predictive performance of the two rival hypotheses. Such a hybrid approach fosters a more comprehensive and rigorous analysis, enabling well-informed and reliable interpretations of study findings while acknowledging and managing the inherent advantages and disadvantages of each statistical paradigm. Deviation from BF 10 = 1, which indicates equal support for the null and the alternative hypothesis , represents the degree of evidence in favor of either H 0 or H 1 . Consensually, BF 10 values greater than 1 are supportive of H 1 , while a BF 10 lower than 1 favors H 0 [34,35]. The mediation analysis was conducted in order to elucidate the role of depression, anxiety, and stress in the relationship between the SF-36 role emotional domain and infertility parameters, i.e., the sperm concentration category and the duration of infertility treatment. Specifically, we aimed to assess whether the effect of infertility on SF-RE was direct or mediated by the levels of psycho-emotional disturbances. --- Results The overview of the descriptive characteristics of enrolled patients, stratified by treatment duration, is summarized in Table 1. With the average height, weight, and BMI of 181.58 ± 7.03 cm, 92.65 ± 18.01 kg, and 27.72 ± 4.01 kg/m 2 , respectively, the majority were overweight or obese, whereas the rest were allocated to the normal weight category. Respondents were predominantly employed residing in the urban setting of the capital city region , childless , and had self-perceived middle-level socio-economic status . Current habitual cigarette and alcohol consumption was present in 29.17% and 56.25% of the studied samples, respectively. According to the IPAQ-SF assessment, three-quarters of the studied men were categorized as active and the cohort-level estimated total energy expenditure was 4262.59 ± 4425.25 MET-minutes per week. On average, the contributions of vigorous, moderate-level intensity, and walking activities were 1711.25 ± 2777.18, 1068.54 ± 1615.75, and 1482.77 ± 1395.10 MET-minutes per week, respectively. The self-reported daily sedentary period featured a broad range from 30 to 960 min and reached the average value of 374.12 ± 188.24 min. Excessive sedentary behavior, i.e., sitting for 540 min or more per working day was recorded for 15 men . Although not reaching the statistical significance threshold, subjects allocated to the low physical activity category had a higher BMI compared to the moderate and high activity groups . Among respondents, fewer than 10% reported repetitive and prolonged exposure to occupational and environmental factors with a postulated detrimental impact on fertility . A review of personal medical records revealed a history of sexually transmitted infections in 13 patients , whereas 9 were previously treated for non-gonococcal urethritis. In total, 15 participants had prior urological surgery, including inguinal hernia repair , and varicocelectomy . The overall burden of chronic non-malignant diseases was relatively low, with hypertension being the most prevalent condition , followed by allergies , diabetes , and respiratory diseases . In addition, four subjects were cancer survivors. Based on participants' report, six had a family history of male infertility. In the analyzed cohort, the infertility treatment duration ranged from 12 to 180 months, with an overall average of 34.80 ± 33.61 months. The reported period pertains to the time dedicated to diagnostic and therapeutic procedures aimed at achieving successful pregnancy. Treatment modalities included a spectrum of the available armamentarium, including the promotion of lifestyle modifications, sexual dysfunction management, treatment of urogenital tract infections, targeted endocrinologic interventions, surgical procedures and, most commonly, application of assisted reproductive technology treatments. Patients may have undergone different procedures either concomitantly or one after another, as the treatment evolved over time based on individual circumstances. Surgical approaches may be categorized into four main groups: interventions aimed at enhancing semen parameters , surgeries to optimize sperm delivery , procedures for diagnostic purposes , and interventions for the retrieval of sperm specifically for in vitro fertilization . No statistically significant differences were observed between the subgroups of patients treated for less or more than two years regarding the anthropometric indices, self-reported lifestyle determinants , physical activity, prior urological pathologies , and the general comorbidity burden, including allergies and cardiovascular , respiratory , hematological , gastrointestinal , and rheumatic diseases , neurological and psychological disorders , dermatologic conditions , endocrine and metabolic disturbances , hepatitis , and cancer . Semen analysis revealed the complete absence of spermatozoa in the ejaculate of 10 patients. Sperm concentrations below the WHO lower reference limit, either isolated or present in conjunction with motility and/or morphology-related spermatozoa deviations, were found in 45 subjects. It is noteworthy that the majority of patients presenting with oligozoospermia had a severe form. The concomitant existence of multiple semen abnormalities, i.e., oligoasthenozoospermia, asthenoteratozoospermia, oligoteratozoospermia, and oligoasthenoteratozoospermia, was detected in 25 , 27 , 31 , and 23 men, respectively. Poor sperm motility was more pronounced among active smokers and men experiencing fertility issues for a longer period of time. Accordingly, among individuals with infertility treatment exceeding two years, there was a significantly higher prevalence of asthenozoospermia 12.667, p < 0.001), oligoasthenozoospermia 10.682, p = 0.001), asthenoteratozoospermia 10.299, p = 0.001), and oligoasthenoteratozoospermia 11.159, p < 0.001). Teratozoospermia was detected in 33 subjects and was always associated with other seminal alterations. Fewer than 10% of the study participants had an abnormally elevated concentration of leukocytes in semen samples, and the majority ) had an ejaculate volume within the reference range . The overall average scores based on the DASS-42 psychosocial distress evaluation were 4.52 ± 4.98, 3.89 ± 4.15, and 10.78 ± 7.83 points for the depression, anxiety, and stress negative emotional dimensions, respectively. A visual inspection of the distribution plots revealed right skewness for all the subscales, and the significant deviation from the normal distribution was confirmed through Kolmogorov-Smirnov tests. A summary of the obtained results featuring each scale central tendency and variability measures, conservative frequentist probability, and Bayesian inference metrics, along with further sample stratification based on conventional ratings from mild to extreme severity, are provided in Table 3. As presented, score discrepancies between patients undergoing infer-tility treatment for less or more than two years were not statistically significant based on a Mann-Whitney U test with the Bayes factors indicating moderate strength of evidence in favor of the null hypothesis for the anxiety and stress domains and weak for the depression subscale. Although it is important to reiterate that particulate domain scores should be primarily regarded as dimensional rather than categorical, the prevalence of subjects surpassing a priori defined cut-off points for depression, anxiety, and stress was 13 , 11 , and 22 , respectively, confirming the established pattern of an absence of statistically significant differences between men treated for less or more than two years 1.118, p = 0.290; anxiety subscale: χ 2 2.122, p = 0.145; and stress subscale: χ 2 0.050, p = 0.824). Strong positive correlations between subscales corroborated conceptually related underlying constructs . Score distributions across eight health-related quality of life conceptual areas comprised in the SF-36 questionnaire are presented in Table 4. Component summary scores ranged from 49.00 ± 6.25 for the mental health dimension to 90.16 ± 17.75 obtained in the physical functioning subscale. Expectedly, correlations between scales were positive and, with a limited number of exceptions, statistically significant . The ceiling effect was observed in physical functioning, role physical, and social functioning domains. When assessed against the infertility treatment period , the between-group difference reached the threshold value of statistical significance only for the role emotional concept. Patients with a longer treatment duration scored lower in this health domain indicating a less favorable state. A significant correlation with the negative direction and moderate magnitude was confirmed with the analysis featuring the treatment period as the continuous variable = 0.270). IPAQ-SF-based estimates of physical activity, expressed as MET-minutes per week, correlated inversely with the bodily pain subscale = 1.361). Patients presenting with semen abnormalities did not differ from their normospermic counterparts regarding the results attained in any of the SF-36 health dimensions. Not surprisingly, significant positive correlations were observed between the scales encompassed by DASS-42, with Depression vs. Anxiety showing Spearman's ρ = 0.544, Depression vs. Stress with Spearman's ρ = 0.540, and Anxiety vs. Stress exhibiting Spearman's ρ = 0.623 , while inverse associations were found between DASS-42 scores and SF-36 health domains. A heatmap plot, as the graphical representation of the correlation matrix indicating both direction and magnitude of the observed associations between these instruments, is presented in Figure 1. Individually constructed mediation models for depression, anxiety, and stress entailed estimations of both direct and indirect effects. The mediation model pertaining to the DASS-Anxiety symptom cluster indicated a statistically significant direct effect of both the sperm concentration grouping and the time-extent of the infertility treatment based on SF-RE, while significant indirect effects were observed only for the treatment duration entity . The mediation model for DASS-Depression yielded less-convincing results, with direct effects demonstrating marginal significance for sperm concentration categories and no significant effects for the treatment duration . Additionally, the model did not reveal any significant indirect effects . Similarly, the mediation model for the DASS-Stress cluster yielded results with only the direct effects of statistically significant levels for the sperm concentration class . The direct effects for the infertility period, as well as indirect, i.e., mediation effects, were all bellow the statistical significance threshold. Total effects of the sperm concentration category and infertility duration based on SF-RE were both significant . This implies that SF-RE is directly affected by the explored infertility parameters and that the effect of the treatment duration is partially mediated by socioemotional distress expressed in the form of anxiety. --- Figure 1. Heatmap correlation matrix presenting associations between The Depression Anxiety Stress Scale and 36-Item Short Form Health Survey questionnaire domains. PFphysical functioning, RP-role physical, BP-bodily pain, GH-general health, V-vitality, SF-social functioning, RE-role emotional, MH-mental health; * p < 0.05; ** p < 0.01; *** p < 0.001. The colors used in the heatmap are designed to convey specific information about the correlations: red indicates a negative correlation, blue represents a positive correlation between two variables, while the color intensity reflects the magnitude of the correlation coefficient. A stronger correlation, whether positive or negative, is depicted by a darker and more saturated color, while weaker correlations are shown with lighter shades. --- Discussion The experience of infertility diagnosis and treatment imposes a complex and mu faceted burden on affected individuals, encompassing not only physical and medical pects but also a plethora of psychological, social, and emotional factors. Involuntary ch lessness may instigate a broad spectrum of negative feelings, including guilt, embarr ment, reduced self-esteem, grief, anxiety, and depression, along with strained interp sonal relationships and social isolation [36]. Furthermore, the impact of infertility m extend beyond the personal domain and affect the couple's bond, sexual functioning, communication [4,37]. The current literature on infertility displays considerable gen --- Discussion The experience of infertility diagnosis and treatment imposes a complex and multifaceted burden on affected individuals, encompassing not only physical and medical aspects but also a plethora of psychological, social, and emotional factors. Involuntary childlessness may instigate a broad spectrum of negative feelings, including guilt, embarrassment, reduced self-esteem, grief, anxiety, and depression, along with strained interpersonal relationships and social isolation [36]. Furthermore, the impact of infertility may extend beyond the personal domain and affect the couple's bond, sexual functioning, and communication [4,37]. The current literature on infertility displays considerable gen-der asymmetry, with a predominant focus placed on the female position [38,39]. Thus, a more comprehensive and gender-inclusive approach in the evaluation and management of infertility-associated distress and its underlying determinants is essential to promote the overall well-being and QoL of those struggling with conception. By employing a multimodal assessment featuring validated self-report questionnaires, physical measurements, and clinical records, the present study sought to shed light on a nuanced interrelationship between physical and psychological factors affecting infertile men in Serbia, thereby addressing the dearth of research on the underrepresented male perspective in this domain. The investigation yielded diverse semen abnormalities in the study cohort, with notable associations between a prolonged treatment duration and reduced sperm motility. Among the participants, 13.54% surpassed predetermined thresholds for depression based on the DASS-42 questionnaire, while 11.46% and 22.92% experienced elevated anxiety and stress levels, respectively. The summary scores from the SF-36 questionnaire demonstrated a broad spectrum, ranging from 49.00 ± 6.25 for the mental health dimension to 90.16 ± 17.75 for the physical functioning subscale. Additionally, patients with longer treatment durations exhibited lower scores in the role emotional domain, indicating a less favorable emotional state. As expected, inverse correlations were observed between the SF-36 mental health score and the DASS-42 subscales. Although occasionally supplemented by advanced and more sophisticated sperm function tests, the routine analysis of semen, exploring the vital parameters, such as the concentration, motility, and morphology, retains its indispensable role as a cardinal procedure in the assessment and treatment of male partners in couples experiencing infertility. Accordingly, in conjunction with a thorough investigation of the reproductive and general medical history and rigorous hormonal and physical examinations, physiologically aberrant spermatozoa remain the primary target of meticulous scrutiny throughout the infertility management [40]. Within the study sample, a remarkable proportion of subjects was observed to manifest severe male-factor infertility, encompassing the conditions of severe oligospermia and azoospermia [41]. As advancements in the comprehensive evaluation of male reproductive function and diagnostic methodologies continue to unfold, these conditions remain a formidable challenge in the realm of infertility treatment [42]. The complete absence of spermatozoa was found in the ejaculate of 10 patients, constituting 10.42% of the study cohort. These findings corroborate the current epidemiologic estimates of azoospermia, indicating a prevalence of approximately 1% among the general male population and notably higher, ranging from 10% to 15%, among individuals diagnosed with infertility [43]. Historically, men diagnosed with azoospermia were categorized as unambiguously infertile, with sperm donation being the primary consideration for achieving parenthood. However, contemporary medical literature and practice have significantly advanced the understanding of azoospermia, revealing that many underlying causes of this condition are potentially reversible, thus offering new options as prospective avenues for restoring reproductive potential [44]. The advancement of knowledge and subsequent paradigm shift in the management of severe male-factor infertility hold the potential of positively influencing the overall QoL experienced by affected individuals. This biomedical evolution not only contributes to the improvement of their psychological well-being, but also acts as a catalyst in alleviating feelings of despair and cultivating a more positive and empowered perspective as they navigate the intricacies associated with confronting such health challenges [45]. This is echoed by the findings of the present study given that no significant differences were observed regarding the overall health-related QoL or psychosocial well-being between azoospermic or oligospermic participants compared to their normospermic counterparts, as measured by the SF-36 and DASS-42, respectively. With accumulating evidence at the confluence of urology and reproductive biology, a general understanding has evolved to recognize that the functional capacity of spermatozoa extends beyond their mere fertilization potential, but rather includes their ability to orchestrate a normal course of embryonic development via diverse genetic and epigenetic mechanisms. These sperm-borne imprints are influenced by multiple paternal variables, such as the genetic makeup, advancing age, and certain modifiable risk-factors [46]. One of the most significant phenomena with adverse effects on sperm quality features is the excessive generation of reactive oxygen species , which may be related to a range of pathologic conditions, environmental exposures, and lifestyle determinants [47]. Asthenozoospermia, present in approximately one-third of study participants, can arise from structural abnormalities or functional impairments of spermatozoa, as well as the deleterious effects of seminal plasma or due to the synergistic interplay of these detrimental factors [48]. Apart from intrinsic causes, such as protein structural defects and genetic disorders contributing to deficiencies in sperm motility, certain physiological processes occurring over the course of sperm maturation and ejaculation may also exert effects via intricate molecular alterations and cellular signaling events. Perturbation of these occurrences and their intensification beyond regulated levels lead to the exacerbation of negative impacts on sperm movement capacity [49]. Within our sample, cigarette smoking emerged as a particularly prominent deleterious contributor among factors associated with oxidative stress and exposure to harmful chemicals, evidenced by the significantly higher prevalence of asthenozoospermia observed among active smokers. These findings are aligned with prior research, including a comprehensive meta-analytical review that summarized published evidence regarding the adverse impact of smoking on semen parameters derived from more than 5000 men using the WHO criteria [50]. The present study revealed a concerning observation regarding the excess weight prevalence among participants, given that the significant majority, exceeding two-thirds, were classified as overweight or obese. A potential association between the escalating incidence of infertility and obesity at a global level has generated substantial interest and apprehension within both the scientific community and public health sectors [51]. Extensive research has been conducted to explore the impact of the detrimental synergy between an increasingly sedentary lifestyle and an unfavorable dietary regimen prevalent in Western societies on the declining reproductive potential among males over the past half-century [52]. The impact of obesity on semen quality and the reproductive-endocrine milieu has yielded conflicting findings and remains a topic of debate and uncertainty in the scientific literature [53,54]. To attain more objective insights on this issue, it has been proposed that the research focus should be directed towards ordinary obese men, rather than infertile individuals, thus mitigating the potential confounding factors present in these patients [55]. Our findings underscore the need for clinicians' awareness regarding both the direct and indirect effects of obesity on fertility, a deeper understanding of the implicated physiological mechanisms and emotional disturbances, and their dedication to the implementation of tailored interventions. While additional investigations are required to fully ascertain the extent of efficacy and the precise role of each recommendation, it is essential to motivate individuals encountering fertility difficulties to maintain a healthy body weight, optimize their dietary habits, restrict alcohol consumption, engage in regular moderate-intensity physical activity, and cease smoking [38]. It is recognized that the experience of involuntary childlessness may exert adverse psychological effects, potentially giving rise to a paranormative crisis that detrimentally impacts men's self-esteem, occupational functioning, and personal relationships, consequently heightening the likelihood of concomitant symptoms of anxiety and depression [56]. The observed rates of men surpassing predetermined DASS-42 thresholds for depression, anxiety, and stress in the analyzed cohort were 13.54%, 11.46%, and 22.92%, respectively. When contrasting our findings with existing literature, it is worth noting that the documented occurrence of psychological symptoms among infertile men exhibits considerable variation across diverse investigations. A Slovenian study involving 353 infertile men attending an outpatient infertility clinic documented anxiety traits in 19.9% of participants [57]. Similarly, in a separate investigation encompassing 771 Chinese men with infertility, the prevalence rates for depression and anxiety were reported as 20.8% and 7.8%, respectively [58]. A Polish study comprising 188 infertile men revealed rates above cut-off points for depression and anxiety as 15.6% and 4.79%, respectively. In contrast, the observed prevalence rates in the Swedish and Italian samples were comparatively lower. The Swedish study reported major depression in 5.1% of males and various anxiety disorders in 4.9% of the sample [59], while the Italian study documented anxious symptoms in 4.5% of men and depressive symptoms in 6.9% of the cohort [60]. These discrepancies may stem from a multitude of factors, such as differences in sample sizes, variations in methodological approaches, and the utilization of diverse measurement instruments. Moreover, it is plausible to suggest that the reported psychopathological profiles are shaped by cultural nuances, as well as the ethnic and demographic contexts in which these studies were conducted. To gain a comprehensive understanding of these symptoms within specific population of infertile men, further research is essential to unravel the intricate underlying determinants. Although the literature indicates that men are more resilient to psychoemotional disturbances imposed by an infertility diagnosis and treatment than women [61], our findings are comparable with those observed using the same instrument, i.e., the DASS-42 questionnaire, among infertile females in Korea [62]. This may be contextualized by the notion documented in previous research highlighting the importance of gender assignment of the underlying cause of the conception difficulties. Namely, men's reaction to fecundity issues approximates to that of women when couple infertility has been attributed to a male factor, regardless of the concomitant presence of a female factor [63]. As per the WHO definition, QoL refers to an individual's subjective evaluation of their life, considering their expectations, objectives, standards, and concerns within the broader cultural and environmental context, societal framework, and personal value system. This holistic concept encompassing both affective and cognitive dimensions conveys the need for a departure from the mechanistic paradigm in contemporary medicine, in favor of integrating a humanistic element into healthcare practices [64,65]. Accordingly, the inclusion of psychosocial aspects alongside biomedical measures in addressing fertility issues has emerged as a pivotal factor in achieving favorable outcomes, as perceived by both clinicians and patients [66]. Score distributions across conceptual areas of the health-related QoL captured by the SF-36 questionnaire in our study exhibited a similar pattern to the findings reported for male partners in large cohorts of Italian [67] and Iranian [68] infertile couples undergoing in vitro fertilization treatment. Notable discrepancy between our study and the aforementioned research lies in the lower scores observed, specifically in the mental health domain within our cohort . Nevertheless, our observations align closely with the investigation conducted by Shindel et al. among American couples experiencing fertility challenges, where male participants demonstrated standardized scores with a mean value of 47.60 based on the mental health subscale of the SF-36 questionnaire [69]. Expectedly, inverse correlations were found between the SF-36 mental health score and those obtained from the DASS-42 depression , anxiety , and stress subscales. Such convergence across employed instruments indicates consistency and supports reliability, thus enhancing confidence in the accuracy and the robustness of the observed findings. While subjective health profiles may not differ significantly between individuals with and without infertility, the duration of treatment appears to exert an influence on patients' QoL [70]. However, reaching definitive conclusions in this regard remains elusive, as the existing literature presents certain contrasting findings, underscoring the intricate nature of the relationship between the infertility duration and its impact on overall well-being. In a study by Ragni et al., it was revealed that a longer period of struggling with infertility could have a detrimental effect on the physical functioning domain of the QoL [67]. Conversely, Rashidi et al. reported that neither the duration of infertility nor its underlying causes exerted a significant influence on the QoL [68]. Our cohort exhibited a statistically significant between-group difference in the role emotional concept of the SF-36, which provides valuable insights into how emotional problems may impact a person's ability to fulfill their daily roles and responsibilities effectively. Specifically, patients with a longer treatment duration demonstrated lower scores in this domain, indicative of a less favorable emotional state. In line with expectations, inverse correlations were found between the SF-36 role emotional score and those obtained from the DASS-42 depression , anxiety , and stress subscales . Furthermore, mediation analysis confirmed that the role emotional domain was directly affected by the explored infertility parameters and that the effect of the treatment duration was mediated by psychological distress expressed in the form of anxiety. The role emotional scale within the SF-36 questionnaire assesses a person's perceived limitations in their daily activities or work due to emotional challenges. It explores three different aspects of these limitations: if the individual felt compelled to reduce the time they spent on work or other regular activities as a result of emotional difficulties; if the person felt that they achieved less in their work or activities than they desired due to emotional issues; whether the individual noticed a decrease in the thoroughness or carefulness with which they carried out their work or activities because of emotional challenges. These findings suggest that extended periods of treatment may contribute to emotional challenges and impede individuals' functioning in their daily lives. Continued research in this area is crucial for a comprehensive understanding of the underlying factors and mechanisms involved, ultimately guiding the development of effective interventions to enhance the QoL of those facing infertility challenges. Investigations conducted across various European countries have reported dropout rates ranging from 17% to 70% among couples undergoing assisted reproductive treatment [71], and it is estimated that in approximately 23% of cases, the premature termination may be attributed to the entailing emotional toll [72]. Hence, it might be prudent for infertility programs to integrate comprehensive psychological vulnerability assessments and establish supplementary counseling services as part of regular protocols, to alleviate psycho-emotional distress that hinders both patients' QoL and treatment outcomes [73]. Enhancing resilience, as a valuable psychological asset, may serve as an effective strategy to mitigate the adverse consequences of psychoemotional disturbances related to infertility. Fostering resilience entails cultivating self-efficacy, developing effective problem-solving skills, and bolstering individuals' ability to cope with the challenges posed by infertility. By harnessing these qualities, individuals are better equipped to navigate the emotional and psychological aspects of their fertility journey, potentially optimizing their overall well-being [74]. Theoretical studies and empirical findings suggest that the perception and interpretation patterns, as well as response trajectories in the reaction to health challenges, including infertility, are gender-specific. Considering the substantial discrepancy in both scientific and practical attention to psychosocial aspects of male infertility compared to the female position, there is a concern that men, known to exhibit a lower propensity for inquiring and engaging in medical consultations than women, may be disadvantaged in terms of receiving appropriate strategies for managing their emotional disturbances. Given the prevailing research emphasis on masculinity as a determinant of men's engagement with medical assistance, the exploration of male needs and the quality of support they receive throughout the illness continuum remains relatively limited, accentuating the necessity for a more comprehensive understanding of these dynamics [75]. Although extensive measures were undertaken to mitigate bias and ensure meticulous data collection and analysis, it is crucial to acknowledge the presence of certain limitations within this study. A noteworthy constraint stems from the implementation of a crosssectional design, which inherently impedes the establishment of the precise temporal sequencing of events and consequently precludes the derivation of causal inferences. While the comprehensive diagnostic process involved a careful examination of the medical and reproductive history, a thorough physical examination with particular attention to secondary sexual characteristics and genitalia, as well as semen analysis, followed by second-level examinations, including hormonal evaluations and microbiological exams, we made a deliberate choice to primarily focus on semen parameters as the cornerstone of male fertility assessments. Consequently, the detailed elaboration of other factors remained beyond the scope of the present article. Due to the lack of baseline data on the QoL and symptoms of psycho-emotional disturbances among the studied individuals before the diagnosis of infertility, the potential for protopathic bias cannot be entirely disregarded. The single-center nature of this research and limited sample size may restrict the generalizability of the findings beyond the specific setting under investigation. The recruitment of men from a specific participant pool within a particular clinical facility raises caution regarding the broader applicability of the results to diverse populations or alternative healthcare contexts. Notwithstanding the potential impact of selection bias, the present study offers relevant evidence regarding the characteristics and experiences of infertile men seeking treatment at a major urology clinic in Serbia, thus contributing to the scarce knowledge base in this filed. Although the utilization of self-reported data brings attention to the potential influence of recall and/or social-desirability bias, proactive measures were made to alleviate their impact. These include the application of validated instruments, standardized investigation procedures, a clear indication of instructions provided by well-trained medical professionals, and the maintenance of a non-judgmental and supportive stance throughout the data collection process, fostering an atmosphere of trust and openness. The inclusion of diverse data sources, such as medical records and clinician assessments, further complemented the self-report data, providing a more comprehensive and objective perspective. Such an approach enhanced the robustness of our study and contributed to a more accurate understanding of the complex factors involved in male infertility and its impact on the QoL. --- Conclusions While it is imperative to conduct further longitudinal and multicentric research to validate and expand upon our findings, the present study offers valuable insights into the intricacies of QoL and psycho-emotional disturbances experienced by men undergoing infertility treatment in Serbia. By delving into the multidimensional nature of the distress faced by these individuals, our research contributes to the limited body of knowledge in this area, highlighting the necessity for comprehensive support strategies that holistically address their unique needs. These findings may serve as a fundamental platform for future investigations, enabling a deeper understanding of the complex dynamics between physical and psycho-emotional factors within the context of male infertility. Such advancements hold great potential for the development of targeted interventions and the delivery of enhanced patient care, ultimately striving towards improved outcomes and well-being for these individuals. --- Data Availability Statement: The data supporting reported results can be found upon request in the form of datasets available at the Clinic of Urology, University Clinical Centre of Serbia. --- Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee, Faculty of Medicine, University of Belgrade . Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. ---

The experience of an infertility diagnosis and treatment imposes a profound burden on affected individuals, encompassing not only physical and medical aspects but also a plethora of psychological, social, and emotional factors. By employing a multimodal assessment featuring validated self-report questionnaires, physical measurements, and clinical records, the present study aimed to explore the quality of life and psycho-emotional distress of men undergoing infertility treatment in Serbia, thereby addressing the dearth of research on the underrepresented male perspective in this domain. Findings revealed diverse semen abnormalities among participants (n = 96, average age 37.69 ± 5.72), with significant associations between longer treatment durations and reduced sperm motility. The observed rates of men surpassing predetermined DASS-42 questionnaire thresholds for depression, anxiety, and stress in the analyzed cohort were 13.54%, 11.46%, and 22.92%, respectively. Summary scores in conceptual areas comprised in the SF-36 questionnaire ranged from 49.00 ± 6.25 for the mental health dimension to 90.16 ± 17.75 obtained in the physical functioning subscale. Patients with a longer treatment duration demonstrated lower scores in the role emotional domain, indicative of a less favorable emotional state. Expectedly, inverse correlations were found between the SF-36 mental health score and DASS-42 subscales. By addressing the existing knowledge gap and highlighting the unique needs of infertile men, the finding of this study may contribute to a more inclusive and holistic approach to infertility research and management.

INTRODUCTION The global scientific community has raced to develop effective and safe COVID- 19 vaccines, yet vaccine development solves only half of the problem in dealing with the threat of the disease. Recent modelling suggests both high efficacy and coverage rates are essential, 1 and a plan for roll-out is crucial. Experience gained from seasonal and pandemic influenza vaccination, [2][3][4] as well as routine childhood vaccination, 5 6 demonstrates that building confidence and effective delivery is a science in itself. An effective COVID-19 vaccination programme will allow societies to resume economic, social and cultural function. This project assists in fulfilling that goal. As of 12 May 2021, there were 99 vaccines in clinical development as recorded on the WHO COVID-19 candidate vaccine landscape database. 7 Open access and paramedic services; general practice respiratory clinics; and COVID-19 testing facilities), aged care and disability care staff , and aged care and disability care residents. 8 The next priority group included all other healthcare workers, household contacts of quarantine and border workers, critical and high-risk workers , people aged ≥70 years, Aboriginal and/or Torres Strait Islander people aged ≥50 years and adults with an underlying medical condition or significant disability. Australia's federal government developed the country's COVID-19 vaccination programme, 9 shaped by a number of health and government bodies. Key among them is the country's national regulator, the Therapeutic Goods Administration, which is responsible for assessing the safety, quality and efficacy of vaccines, including any COVID-19 vaccines. The Australian Technical Advisory Group on Immunisation also provides technical input for a COVID-19 vaccination programme, tasked with identifying priority populations for vaccination. The federal government and the governments of the states and territories share responsibility for programme implementation, through national and local implementation plans. Australia has experienced relatively little community transmission since the pandemic began, especially compared with culturally similar contexts like the USA, UK and Continental Europe. This is particularly the case in Western Australia , which, until early February 2021, had no community transmission of the virus for nearly 10 months, 10 and has had very little community transmission since. 11 The country and its states and territories have implemented strict border controls, restricting visitors and enforcing 2-week quarantines. Australia, and WA within it, is therefore a unique place to study the public's views on and acceptance of COVID-19 vaccination. With relative safety, for instance, comes the possibility that people may delay or avoid vaccination. This unique Coronavax study is therefore necessarily sensitive to barriers and challenges to vaccination that may arise in Australia and globally. Australians are generally highly supportive of vaccination, with 87% believing that vaccines are safe, effective and necessary 12 ; less than 6% of Australians do not believe that vaccines are safe. 13 However, recent pandemic experience with influenza A/H1N109 saw poor vaccine uptake. One study found 26% of refusers were concerned about safety and 17% did not believe in the vaccine. 14 Studies conducted between April and June 2020 found between 65% and 86% of Australians were likely to accept the COVID-19 vaccine. [15][16][17] The WHO listed 'vaccine hesitancy' as one of the top threats to global health in 2019, 18 even before the pandemic. Hence, implementing an evidence-based plan for COVID-19 vaccine roll-out is crucial. To facilitate an effective COVID-19 vaccination programme, scholarship needs to inform COVID-19 vaccine communications and to help develop effective mechanisms of governance for a vaccination programme. Governments must understand what communities require and identify the factors enabling widespread vaccine acceptance. A central aim of this project is therefore to facilitate communication between governments and members of the public. Communities are not homogenous, and they will need different messaging, encouragement and access based on their demographic features, values, locations and experiences of disease threat and lockdown. 19 Building and maintaining trust is central, as mistakes can have lasting and devastating repercussions. Previous pandemic vaccine roll-outs demonstrate this; for example, in France, a challenging and rapidly implemented roll-out of the influenza A/ H1N1 vaccine united a heterogeneous front of vaccinehesitant populations. 20 Engaging transparently and continuously with those who might undermine vaccination programmes through holding or disseminating negative views of vaccination is best practice in risk management, and increasingly important in the age of social media. 21 The project facilitates communication and ensures shared understanding between communities and governments during COVID- --- Open access Social media study design, sample and analysis Social media is increasingly important as a source of information and disinformation for the broader public. The social media component of the study involves monitoring social media platforms used by local communities, in order to stay abreast of real-time concerns or controversies. This process will involve weekly searches for mentions of the COVID-19 vaccine in various social media channels and the collection of data based on those searches. It is not expected that these searches will comprehensively collect all mentions of the vaccine on social media, rather it is seen to be enough coverage to provide an overview of prominent and emerging concerns. This broad data collection will provide the basis for more targeted research about the origin and spread of concerns and controversies about the vaccine and the evolution of vaccine sentiment over time. The resulting data will be analysed using both discourse analysis and network analysis. The type of data to be collected includes: ► Comments and posts made by social media users, pages and groups. ► Interactions with these messages, such as shares, retweets and reactions. ► Basic demographic data shared publicly on social media. Such data may include location, gender and age. This aspect of the study collects data that may influence public sentiment. We will only use data from the public domain and include only publicly available posts and comments. The majority will be from search tools available to anyone-specifically Twitter, Instagram, TikTok, YouTube and Facebook's Search Console, Google Trends, Google Search and BoardReader . There may be some use of curated data in order to make the search for relevant data easier. For instance, Facebook have provided academic access to their 'Crowd-Tangle' application, allowing researchers on this project access to data on the spread of information via Facebook, Reddit, Instagram and Twitter. CrowdTangle allows us to monitor discussions in Facebook pages that are used by cultural and linguistic minority communities, as well as information provided by advocacy organisations through that platform. The data that Facebook releases via this application are only that which are publicly available. The access provided for this project collates data on posts with the highest number of public interactions. This does not include private Facebook groups or personal profiles. Accounts established on Instagram, Twitter, TikTok and YouTube manually follow stories about the COVID-19 vaccine, accessed weekly in order to assess and code what sort of information about the vaccine each platform algorithmically selects as 'recommended' for these accounts. We do this by coding the first 10 stories or posts in each feed. The naming of these accounts makes it clear that they are research accounts, and they only view and follow COVID-19 vaccination stories and posts. The data collection schedule includes a weekly scrape of the top posts on each feed and platform. NVivo 22 capture gathers data such as message content, source and engagement, which is then stored for analysis. Social media data is analysed in two ways: 1. Discourse analysis: this involves looking at people's comments and overall concerns. Frameworks that used to code data and analyse discourse include, but are not limited to: -Media type. -Level of engagement. -Stated concerns about the vaccine. -Identifying where messages position themselves in terms of Leask et This research has significant benefits in terms of monitoring and reporting the spread of information about COVID-19 vaccination programmes. It will also help improve understandings of how information spreads through social media networks. This knowledge will help guide public health communication during the roll-out of the coronavirus vaccine as well as informing future public communication programmes and initiatives. Network data will be analysed using UCINet 24 and Statnet 25 for R. --- Community interviews study design, sample and analysis The project involves semistructured in-depth interviews of approximately 1 hour with those living in WA. As determined by the research team in collaboration with the WA Department of Health, interviewees include those who need the vaccine first, but also those who possess the capacity to undermine a vaccination campaign through holding or disseminating negative views of vaccination. 26 Open access 8. Parents/guardians of children aged 5-18 years, with comorbidities. 9. Parents/guardians who are hesitant about routine childhood vaccines. 10. Aboriginal and Torres Strait Islander people in Perth. 11. Adults in regional or remote areas of WA. 12. Culturally and linguistically diverse people. 13. Adults with comorbidities. 14. Service delivery organisations for especially vulnerable populations such as the homeless, drug dependent and victims of domestic violence. Methodologies for engagement with these groups will be developed based on best practice, including the use of translators and interpreters where necessary. 15. Pharmacists. Participants discuss their experiences and views of the pandemic and lockdown period/s, as well as their views regarding COVID-19 vaccination in WA . Participants answer additional questions depending on which categories they are in. A number of participants may belong to one or more of the categories, for instance, interviewee 'X' might be an adult, working in aged care, who has a child under the age of 5 years. They would therefore receive generic adult questions with additional questions related to their occupation and being a parent to young child. In order to ensure the sample includes the target groups and is as diverse as possible, participants are prescreened using Research Electronic Data Capture software. REDCap is a secure, web-based software platform designed to support data capture for research studies, providing an intuitive interface for validated data capture; audit trails for tracking data manipulation and export procedures; automated export procedures for seamless data downloads to common statistical packages; and procedures for data integration and interoperability with external sources. 29 30 The prescreening survey first captures important demographic details that enable screening for particular types of participants, in addition to providing contact details and preferences for interviews days and times . Participants then have the option of continuing to a follow-up survey in REDCap, or of answering these follow-up questions during their interview. Questions in the second survey capture important information about participants that are not necessary for the purposes of screening . Brochures, posters, word of mouth and media releases distribute the prescreening survey in the Perth metropolitan area . The design of posters and brochures was in collaboration with the Telethon Kids Institute communications and graphic designer team. Recruitment also draws on investigators' existing networks. If recruitment through community-based methods is insufficient, there will be further recruitment through government and non-government workplaces and institutions . A number of groups, such as parents/guardians who are hesitant and/or resistant to childhood vaccines, may be difficult to access. However, KA has previously worked with such parents. 31 They will be recruited through the channels described above at 2.2, with an emphasis on the use of personal networks, maintaining confidentiality and providing distance from personal relationships . --- Open access Information and consent materials for the project explain the research's basis in improving vaccine uptake. This provides transparency for participants, who can take the opportunity to share their critiques and concerns through the research as they have through KA's previous work. Research with Aboriginal and/or Torres Strait Islander people should be led by Aboriginal and/or Torres Strait Islander people and communities. The research team must include Aboriginal and/or Torres Strait Islander members, and the priorities should be guided by the community with whom the researchers intend on recruiting within. 32 Thus, to assist with recruitment and interpretation of the views of Aboriginal people in Perth , an Aboriginal cultural guidance advisor and researcher has been engaged . With the recent awarding of additional funding , we are employing an Aboriginal researcher to undertake extensive community consultation and to later conduct interviews in a culturally sensitive fashion with this priority group for COVID-19 vaccination in Australia. 34 These interviews will be conducted with Aboriginal people in Perth; this community predominantly uses English as their main language spoken at home. 35 Research with Aboriginal people in regional areas remains in the project plan. Interviews may be conducted by video chat, phone or in person. For the bulk of participant groups, face-toface interviews are the preferred method, dependent on COVID-safe policies and recommendations at the time of interviews. For people less eager to participate in face-toface interviews or who face technological barriers, alternative methods are employed. Thematic analysis of the data uses NVivo V.12 software. 22 This analytical process will be collaborative, with inductive themes decided jointly by the research team based on research questions, and then revisited throughout the analysis deductively with the emergence of new themes. Analysis will follow the steps outlined in the Braun and Clarke method. 36 If post-interview clarifications or additional information is required, investigators may follow-up with participants . Data collected in these follow-up conversations may be included in the project findings. --- Functional dialogues study design, sample and analysis Coronavax is centrally concerned with vaccine governance. Regular functional dialogues take place with relevant government departments and committees within WA and Australia. These : study how policymakers understand and implement the tools available to best drive vaccine uptake; ensure rapid dissemination of emerging insights from ongoing fieldwork to stakeholders in WA and federal governments; and encourage stakeholders and the research team to shape fieldwork through collaboration. Investigators work with government partners to identify key individuals who: have used or will use the emerging findings, and can speak on behalf of their team/department, including in terms of providing feedback to inform the ongoing conduct of each Coronavax component. Researchers from the Coronavax research team are selectively included when discussing relevant findings or project components. A facilitator from the research team leads each functional dialogue . Conversations follow a semistructured discussion framework, giving time for research dissemination and in-depth conversations between researchers and stakeholders while exploring stakeholders' attitudes, beliefs, experiences, roles and observations in detail. Meetings with local participants will be face to face, or via online videoconferencing if it is not COVID safe to meet face to face. Functional dialogues with federal participants are via videoconferencing. This is necessary in light of current internal border closures and travel restrictions within Australia. --- Open access Mapping evidence uptake and use study design, sample and analysis Coronavax's interest in vaccine governance will also focus on knowledge sharing by government stakeholders and policymakers. To do so, investigators will conduct a quantitative social network analysis of WA state government employees intra/inter stakeholder information-sharing networks recruited through the functional dialogues . Social network analysis enables the research team to both visualise the structure of stakeholders and analyse the properties of these relationships. This enables investigators to understand how evidence travels through government. This has two benefits: identifying blocks to communication, and helping stakeholders to redesign their communication networks to achieve more effective working practices. Data collection is through a short nine-item structured questionnaire, administered by hand and online using Qualtrics survey software 37 . Themes in the questionnaire include knowledge, understanding and use of Coronavax findings; internal colleagues with whom the participant discusses COVID-19 vaccine roll-out; and external colleagues with whom the participant discusses COVID-19 vaccine roll-out. Data gathered through the questionnaire will be analysed using the specialist social network analysis software UCINet. Investigators will explore the overall structure of the communication network as well as the existence of any structurally important actors in the network . Part of the discussion will focus on evidence-sharing networks. Using these suggested connections, the research team will be able to 'snowball' and identify relevant departments/teams as potential respondents to the survey. 38 Patient and public involvement Consumers have informed the project's design, which has been undertaken with three main goals in mind: 1. Ensure the appropriateness and sensitivity of research questions and recruitment. 2. Ensure that the research priorities and design reflect the needs of the community. 3. Explicitly bring the consumer voice back to government as part of the functional dialogues. Involving advocates and trained consumer representatives and related organisations, such as the Immunisation Foundation of Australia and 'Light for Riley' online vaccine advocacy campaign, is central to the project's community engagement strategy. Consumers advise on the community interviews and contribute to all sections of the protocol. This approach is supported by a network of consumer involvement experts from the TKI and the Consumer and Community Health Research Network, including the Wesfarmers Centre of Vaccines and Infectious Diseases Community Reference Group . This community reference group consulted on Coronavax in September 2020. --- ETHICS AND DISSEMINATION This project has ethical approval from the Child and Adolescent Health Services Human Research Ethics Committee under permit number RGS0000004457. The University of Western Australia HREC reciprocally recognised this approval under permit number 2020/ ET000339, and separately granted ethical approval for the federal functional dialogues under permit number 2020/ET000340. Our protocol has undergone three amendments with more pending to include new community study cohorts for which we have attained additional funding. These have been explicitly detailed above. Participants and their workplaces or institutions are given pseudonyms, ensuring that their anonymity is respected in any communications and publications arising from this research. Publications and presentations will omit specific information that may identify participants. Participant data are manually reidentifiable and will only be accessed and analysed by the researchers. Identifying details collected in the prescreening survey of the community interviews are stored on REDCap. All audio transcripts created during the community interviews and functional dialogues are stored temporarily with Otter and permanently deleted following transcription. 39 Audio files collected in the community interviews and functional dialogues, transcripts, evidence-mapping survey data and any other non-identifying information are stored under associated pseudonyms on UWA's Institutional Research Data Store . IRDS supports the requirements of researchers regarding confidentiality, integrity, availability, security and ownership of data. 40 Investigators will keep the project data on UWA REDCap and UWA IRDS . All hard copy documents obtained during the research will be stored in a secure filing cabinet in the lead author's office. Investigators will securely destroy them at the time of electronic data disposal. Investigators anticipate publishing several articles from each Coronavax component in peer-reviewed journals that publish articles on vaccines; infectious diseases; medicine; public health; social sciences; relationships; family; employment; anthropology; gender; and health sociology. Project investigators will also share results more widely, including with and through the media, as well as by presenting at conferences and seminars. Contributors KA conceptualised the project, convened and managed the research team and worked in collaboration with each component lead to design the project. She also led the research funding applications and wrote the core sections of the protocol as well as editing and drafting this protocol manuscript. SC was responsible for writing the core sections of the protocol, collated and managed the contributions of coauthors to the protocol, contributed to the writing of funding applications, managed the HREC application process, as well as drafting and editing this protocol manuscript. JT wrote the core sections of the protocol, designed the functional dialogues and evidence uptake and use mapping, contributed to the development of the social media study and managed the ethics applications to UWA HREC application for functional dialogues with federal policymakers. TH wrote the core sections of the social media study and had input on the functional dialogues section. He is the research team leader for the social media study. LM led the design of the community interviews with KA and SC, cowrote the relevant sections of the protocol and contributed to the editing of this manuscript. LR assisted with the design of the community interviews and contributed to the editing of this manuscript, including preparing the appendices. MR contributed to the conceptualisation of the project with regard to the role of the government in vaccine roll-out, the development of the functional dialogues with JT and he assisted with the ethics application to UWA HREC. DW provides institutional liaison with the Department of Health, Western Australia, and has contributed to the project design. He contributed to the editing of this manuscript. PE represents with the Department of Health, Western Australia, and has contributed to the project design from its inception. CH contributed to the project's consumer involvement plan, and provided consumer insight relevant to the protocol, participant information sheets, participant recruitment materials, community interview questions and social media project. VS, an Aboriginal woman and Aboriginal cultural governance advisor to the Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, provided leadership and guidance to ensure this project addresses the needs of First Nations families. She continues to shape the team's culturally secure recruitment and engagement for its ongoing research programme. CCB has contributed significant medical, technical and research expertise to all aspects of this project. He has led funding applications and provided resources, engaged in high-level conceptualisation of the project in its entirety and led key aspects of its stakeholder engagement. He contributed to the writing of the protocol as well as the drafting and editing of this protocol manuscript. All authors contributed to the editing of this manuscript. Funding Funding for this project was provided by a Wesfarmers Centre of Vaccines and Infectious Diseases 2020 Catalyst Research Grant and the Government of Western Australia's Department of Health . A subsequent Future Health Research Innovation grant from the Government of Western Australia funds additional community sub-group interviews. KA is funded by the Australian Research Council of the Australian Government under DEDE190100158. She has previously received a speaker's fee from Merck. Disclaimer The funding providers, organisations involved in the study and individual members of the research team have no financial interest in the outcome of the research. Government funding partners will contribute to the research question design and contribute to the functional dialogues, although not to their research design. All funders will also participate in the dissemination of research findings. --- Competing interests None declared. Patient consent for publication Not required. Provenance and peer review Not commissioned; externally peer reviewed. Supplemental material This content has been supplied by the author. It has not been vetted by BMJ Publishing Group Limited and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations , and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Introduction Ahead of the implementation of a COVID-19 vaccination programme, the interdisciplinary Coronavax research team developed a multicomponent mixed methods project to support successful roll-out of the COVID-19 vaccine in Western Australia. This project seeks to analyse community attitudes about COVID-19 vaccination, vaccine access and information needs. We also study how government incorporates research findings into the vaccination programme. Methods and analysis The Coronavax protocol employs an analytical social media study, and a qualitative study using in-depth interviews with purposively selected community groups. Participant groups currently include healthcare workers, aged care workers, first responders, adults aged 65+ years, adults aged 30-64 years, young adults aged 18-29 years, education workers, parents/ guardians of infants and young children (<5 years), parents/guardians of children aged 5-18 years with comorbidities and parents/guardians who are hesitant about routine childhood vaccines. The project also includes two studies that track how Australian state and Commonwealth (federal) governments use the study findings. These are functional dialogues (translation and discussion exercises that are recorded and analysed) and evidence mapping of networks within government (which track how study findings are used). Ethics and dissemination Ethics approval has been granted by the Child and Adolescent Health Service Human Research Ethics Committee (HREC) and the University of Western Australia HREC. Study findings will be disseminated by a series of journal articles, reports to funders and stakeholders, and invited and peer-reviewed presentations.

An alternative possibility is that SES differences in child-directed speech may be explained in part by broader contextual factors that exert influence on parenting behaviors. In line with this perspective, Conger and colleagues have developed and tested the Family Stress Model to explain how economic pressures affect family functioning and individual adjustment, and consequently, a broad range of child development outcomes [23][24][25] . More specifically, financial stress is posited to impact aspects of caregiving including warmth, sensitivity, and cognitive stimulation-activities such as reading aloud, play, and other interactions that involve child-directed speech and support children's language development. For instance, Nievar and colleagues 26 showed that lower income predicted reduced positive parenting behaviors such as responsiveness to infant vocalizations, which then predicted children's later cognitive outcomes in the first grade. There is also evidence suggesting links from economic concerns to parenting stress and depression and in turn, child language [26][27][28][29] . Moreover, though initially conceptualized to explain family processes among low-SES families, evidence suggests that the Family Stress Model applies to families across varying socioeconomic levels 30,31 . Ponnet 31 hypothesized that although the nature of financial concerns may differ at different levels of SES, the subjective experience of worrying about finances is likely to impact parenting and family functioning across families from a range of SES backgrounds. Indeed, recent surveys suggest that Americans across the SES continuum are financially stressed. Less than 4 in 10 Americans state that they would be able to pay a surprise $1000 bill from their savings 32 and of individuals who make over $100,000 a year, over 30% regularly run out of money between paychecks 33 . The idea that financial concerns impact parents' capacity to interact with their children complements a growing body of research showing that specific structural sources of stress such as resource scarcity affect adults' psychological functioning and cognitive processes [34][35][36][37] . Mani and colleagues 38 suggest that when a particular resource is scarce, this taxes cognitive resources and individuals shift their attention to focus on the scarce resource at the expense of other issues that might require attention. This can lead to counter-productive behaviors such as anxiety, forgetting, attentional neglect, and poor decision making [39][40][41] . For instance, Shah et al. 40 conducted a laboratory study in which participants were given either rich or poor budgets to play a version of Wheel of Fortune, after which they completed a task measuring cognitive fatigue. Participants with poor budgets demonstrated more cognitive fatigue, suggesting that resource scarcity caused those with poor budgets to increase focus during the game, which in turn resulted in reduced cognitive function on the later task. Additional findings from Shah et al. 36 speak to how financial concerns influence individuals' everyday experiences. Through several experiments, Shah and colleagues showed that individuals who were not necessarily poor but had constrained budgets were more likely than higher-income individuals to think about financial concerns when contemplating daily events that involved an economic dimension , were more likely to do so unprompted, and found it difficult to suppress thoughts about the cost of common activities when instructed not to think about it. Complementary evidence suggests that reducing financial concern can improve cognitive function 39,42 . For instance, Ong et al. 39 demonstrated that providing debt relief to individuals with chronic debt resulted in improvements in their inhibitory control abilities and reductions in anxiety. Financial strain is not experienced as a steady state for all families. Instead, it varies over the course of the month due to timing in paydays, distribution of public assistance benefits, and when bills are due. Two recent studies by Carvalho and colleagues showed that in the US, paydays and other income sources are distributed 1-2 times per month and are most frequently paid at the beginning of the month 43 . In the state of California, where the present research was conducted, public assistance benefits are typically paid within the first 3 to 10 days of each month and credit cards and other bills are frequently due at the beginning or middle of each month [44][45][46] .This timing corresponds to families spending less on groceries and other goods later in the month, when Americans report that they are less financially secure 33,[47][48][49] . If parent-child interactions are impacted by financial strain, as suggested by the Family Stress Model, then variation in financial strain over the course of the month should be linked to corresponding variation in parent and child behavior. Findings from several recent studies that have used the date of the month of an indicator of financial strain are consistent with this possibility. For instance, one study found that elementary-school children's disciplinary infractions spiked at the end of the month, and this pattern of findings was most apparent in children whose families receive SNAP benefits, which are distributed early in the month 50 . In addition, reducing financial strain at later points in the month via changes in benefit distribution is associated with reductions in crime and grocery store theft 51 . Finally, the impacts of financial strain on cognitive load have also been linked to payday timing. In a study by Burlacu et al. 52 , priming financial worry among parents impacted their budgeting for immediate household needs as opposed to child learning products such as books, despite the presence of subsidies for the child products. These impacts were most pronounced among those who were furthest from their payday, suggesting that the timing of financial concerns reduced their decision-making capacities. Building on this body of research, Ellwood-Lowe and colleagues 53 recently proposed that the cognitive load imposed by resource scarcity could directly suppress parent talk: if parents' attention is occupied by financial concerns, this leaves less attention to devote to child-directed speech. They tested this hypothesis in two ways. In one study, scarcity was experimentally manipulated in a laboratory setting by prompting caregivers to reflect on times in the prior week when resources were scarce. Parents' child-directed speech was then examined during a play session and compared to a control group that was not prompted to reflect on scarcity. Not all parents reflected on financial scarcity when prompted, but those who did spoke less to their 3-year-olds than parents who failed to reflect on financial scarcity and parents in the control group. In a second study, Ellwood Lowe et al. examined corpora of day-long in-home recordings to test whether parents' speech decreased near the end of the month which, as noted previously, is when Americans report experiencing greater financial strain 33,49 . Results showed that parent-child conversational turns tended to be lower in the last week of the month compared to earlier weeks, though this finding only emerged in 1 of the 3 corpora examined. The authors concluded that above and beyond individual characteristics of parents, financial concerns may impact the tendency to engage in child-directed speech. These findings from Ellwood-Lowe and colleagues 53 provide initial suggestive evidence for a link between financial concern and parents' child-directed speech. However, there was limited variation in family SES in both studies. In the first study, the majority of parents were high SES: the median household income was over $150 k per year, and a third of the parents reported a household income over $200 k per year. Although the SES levels in the second study were somewhat lower and more variable than in study 1, the majority of parents were still from middle-to upper-middle class backgrounds. Moreover, the single corpus where the effect of the week of the month was significant happened to have the highest reported family income, and 50% of the mothers in this corpus had a graduate degree . Thus, it remains unclear whether the impact of financial stress on child-directed speech is robust, and whether it operates across SES levels, as the Family Stress Model would predict 25 . The present study tested the claim that financial concern suppresses child-directed speech. Using two existing corpora of lab-based parent-child interactions from socioeconomically diverse samples , we examined whether parents' speech to their children varied over the course of the month. As discussed above, Americans tend to spend more money during the first and third week of the month and less in the last week of the month 47 , and report greater financial concern later in the month 33,[47][48][49] . Financial concern is likely to be particularly salient in the state of California, where the present corpora were collected: California is ranked second in the nation for cost of living and is home to 33 million families living paycheck to paycheck 54,55 . Benefits in California are also paid early in the month, and thus financial concern should be greater later in the month 44,45 . We therefore hypothesized that the quantity and diversity of the child-directed speech that parents produced during an interaction with their child would be negatively associated with the day of the month in which the interaction took place. We reasoned that if this pattern emerged in a lab-based interaction where it was salient to parents that their speech to their child was being observed, this would provide particularly strong evidence that financial strain suppresses child-directed speech. --- Results Participants were parent-child dyads from two existing corpora in which dyads completed an interactive picturebook activity. Interactions were recorded, transcribed, and coded for three measures of parent language: number of utterances, number of word tokens, and number of word types . We then examined whether these measures varied as a function of the day of the month that the lab visit and parent-child interaction took place . Four parents had utterance counts that fell more than 3 standard deviations above the mean for this measure. Excluding these dyads from the analyses of parent utterances did not affect the patterns of significance reported below, so we retained them in the analyses. There were no outliers for word tokens or word types. Six parents spoke Spanish for a portion of the interaction. All of the patterns of significance reported below remain the same if these dyads are excluded. Preliminary analyses revealed no significant effects involving child sex, parent sex, or ethnicity, all ps > 0.15. We therefore collapsed across these factors in subsequent analyses. --- Child race White 120 Black/African American 4 Asian 8 Hawaiian or Pacific Islander 1 Native American 1 More than one race 9 Other race 14 NA 9 --- Child ethnicity --- Hispanic or Latino 83 Non-Hispanic or Latino 80 NA 3 --- Highest degree completed by either parent --- Highschool or less 36 Associate's degree 35 Bachelor's degree 53 Master's/PhD/professional degree 42 Zero-order bivariate correlations revealed that, as predicted, the day of the month that the parent-child interaction took place was significantly negatively correlated with the number of parent utterances, r = -0.20, p = 0.011, word tokens, r = -0.19, p = 0.014, and word types, r = -0.16, p = 0.04 . To determine whether visit day significantly predicted parent talk after accounting for demographic variables and corpus, a hierarchical multiple regression model was conducted for each parent talk variable. In each model, child age, corpus, and parent education level were entered at Step 1, and visit day was entered at Step 2. Finally, to test whether the effects of visit day varied across socioeconomic strata, interactions between visit day and parent education level were entered at Step 3. As shown in Table 3, there were no effects of child age or corpus in any of the models. The effect of visit day was significant in all three models, and this effect did not interact significantly with parent education level. Thus, parents who participated later in the month produced less speech and their speech was less diverse, regardless of their level of education. To facilitate comparisons with Ellwood-Lowe et al. 53 , we compared parent talk during the last week of the month to the rest the month . For each parent talk variable, we conducted an analysis of variance with visit week and parent education as between-subjects factors. These models revealed a significant effect of visit week on the number of parent utterances, F = 5.82, p = 0.017, η 2 = 0.04, and the number of parent word tokens, F = 4.23, p = 0.041, η 2 = 0.03, and a marginal effect of visit week on the number of parent word types, F = 3.66, p = 0.058, η 2 = 0.03. There were no significant effects of parent education = 0.17, p = 0.92; tokens: F = 0.33, p = 0.81; types: F = 0.24, p = 0.87) and no significant interactions of visit week and parent education = 0.36, p = 0.78; tokens: F = 0.96, p = 0.41; types: F = 1.45, p = 0.23). Because time of the month was not a factor of interest in the original studies from which these data were derived, the timing of study visits was not controlled: appointments were scheduled on the day the parents chose. This raises the possibility that visit day was confounded with other participant characteristics that could impact parent talk. A final set of analyses indicated that visit day did not vary as a function of child sex, parent sex, ethnicity, or corpus, all Fs < 1, all ps > 0.76. There was a marginal effect of parent education on visit day, F = 2.54, p = 0.058, η 2 = 0.05. Examination of this marginal effect revealed that the visit day of parents in the High school or less group was somewhat earlier in the month than the visit day of parents in the Although the reason for this sampling difference is unclear, the direction of this effect means that the lower levels of parent speech observed on later visit days were not due to oversampling low-SES parents later in the month, as these parents tended to participate earlier in the month. More critically, all of the significant relationships between parent talk and visit day held after controlling for parent education, and no interactions emerged between visit day and parent education in any of our analyses. Together, these analyses suggest that the relationship between visit day and parent talk was not driven by any of the participant variables that were available in the data set. --- Discussion Considerable evidence suggests that parents' engagement in child-directed speech is related to a number of important aspects of child development, and in particular, language development 1,2,22 . It is therefore critical to consider potential sources of variability in parent talk. In the current study we examined one possible source of variation that has been hypothesized to exert influence on parents' use of child-directed speech: financial concern 28,53 . We used existing corpora of lab-based parent-child interactions and examined whether parents' speech to their children varied over the course of the month. We predicted that parents would talk less near the end of the month when financial concerns were likely to be greatest 33,[47][48][49] . Consistent with this hypothesis, results showed that the number of utterances, word tokens, and word types that parents produced were negatively correlated with the date of the month when they participated in the parent-child interaction. These associations remained after accounting for child age, corpus, and parental education. Finally, as one would expect if financial strain were highest at the end of the month, parents who participated in the final week of the month produced significantly fewer utterances and word tokens and marginally fewer word types than parents who participated earlier in the month. These findings provide the first evidence that the time during the month that a parent-child interaction occurs relates to parents' use of child-directed speech in a socioeconomically diverse sample. Parents in the current study varied considerably in their level of education and they were drawn from a region where families tend to have lower socioeconomic status than other parts of the state or country. The current findings therefore replicate those reported by Ellwood-Lowe and colleagues 53 , who tested primarily middle-to upper-middle class families, and extend them to a more socioeconomically diverse sample. The fact that time-dependent differences in child-directed speech emerged in a more socioeconomically diverse sample suggests that the impact of financial concern on child-directed speech is robust and operates across SES levels. These findings suggest that above and beyond individual properties of parents, broader contextual factors such as financial concerns exert influence on the way parents interact with their children. Our findings are consistent with the Family Stress Model, which posits that economic hardships, such as low income or high debt-to-asset ratio, increase economic pressures, which negatively affect family functioning and parent adjustment, and consequently, child development outcomes [23][24][25] , including language [27][28][29] . Although we did not directly measure financial strain, we hypothesize that in the current study, parents participating at days later in the month were more occupied with financial concerns, which affected the speech they used in interactions with their child. If this is the case, then these results suggest that economic strain plays a role in parents' capacity to interact with their children. Moreover, our analyses revealed no effect of education on parents' child-directed speech, suggesting that families from high-and low-SES backgrounds were similarly influenced by the date the interaction took place, as well as the potential corresponding economic pressure. Although families from low-and high-SES backgrounds likely experience financial strain very differently from one another, the current findings suggest that financial strain can nevertheless have impacts on parental language across SES levels. Our results therefore add to the growing body of findings suggesting that these processes are not specific to families living in poverty 31 , and that the Family Stress Model applies to families experiencing financial concerns across socioeconomic strata. The current findings also extend prior work by showing that parents' child-directed speech was lower at later points in the month in a context where it was particularly salient that they were being observed. Parents were given instructions on how to interact with their child and then were left in a room where video recording devices were clearly visible. The fact that parental talk varied across the month despite these cues and despite the potential urge to engage in high levels of child-directed speech due to social desirability bias is well-aligned with the hypotheses set forth by Mani and colleagues regarding scarcity [34][35][36][37] . In particular, these findings complement laboratory and field research showing how financial concern operates in everyday life and that these cognitions can arise spontaneously and are difficult to suppress 36 . In the case of the current study, the influence of financial concerns surfaced even in the face of cues that might otherwise enhance parental talk. Our finding that parents engage in less child-directed speech at later points in the month is consistent with those reported by Ellwood-Lowe and colleagues 53 , who examined day-long recordings collected in the home. However, this latter finding was only significant in one of the three corpora examined. This pattern of results raises the possibility that the influence of financial concern on parent speech might be greater in laboratory settings than at home. Contrary to our suggestion that being observed might have enhanced parent talk, one might instead argue that being in a laboratory could enhance effects of financial concern because parents experiencing more stress might be less able to "perform" under scrutiny. If so, then the impact of financial concern on child-directed speech might be less evident in home environments. Although possible, prior research examining the speech used in parent-child interactions has revealed converging findings across laboratory and home assessments 12,56-60. In particular, recent work examining the association between SES and child-directed speech found that location of the assessment did not significantly moderate this relationship 12 . This converging evidence across methods suggests that lab-based measures of parent language, such as the picturebook task used in this study, tap into consistent patterns of behavior that are reflective of children's everyday experiences. We therefore think it likely that our findings reflect a more general impact of financial concern on parents' child-directed speech that would also emerge in the home setting. Nevertheless, it would be worthwhile to replicate the present findings in naturalistic settings to clarify in which contexts financial concern impacts parents' child-directed speech. A second question is whether the current findings would generalize to other participant samples. The current findings and those reported elsewhere suggest that in the US, the effect of financial concern on parent-child interactions is not specific to lower SES families. However, this effect might differ for very low SES families, such as those living well below the poverty line. Notably, some racial and ethnic minority groups experience higher levels of stress, earn lower wages, and are more likely to live in poverty [61][62][63] . This also raises the question of whether our results would emerge across racial and ethnic groups in the US. In the present study, approximately half of the participants were Hispanic or Latino, but we found no effects of ethnicity. However, we did not have information regarding parents' immigration status, country of origin, or levels of acculturation, which could affect parents' child-directed speech [64][65][66] . Similarly, we only examined the quantity of parent talk. Some research suggests that the style and content of parents' language varies with ethnicity 67 . It is therefore possible that other aspects of parental talk might vary by day of the month and ethnic background. In terms of the broader global population outside the United States, prior research has shown that the timing of paydays and harvest schedules that are likely to produce financial stress in non-Western cultures correspond to changes in performance on cognitive tasks 35,39,68,69 . These findings could indicate that scarcity impacts cognitive function similarly across cultures, but it remains an open question whether this would also impact parent speech and in turn, child language and other developmental outcomes. In studies within the United States, there is strong evidence showing associations between SES, children's language environment, and children's language development. In contrast, in other parts of the world such as in Southern Mexico and Bolivia, children are exposed to less child-directed speech, and despite this, achieve language learning milestones on a typical trajectory consistent with children in the United States [70][71][72] . Given the infrequency of child-directed speech, it is possible that financial concerns may not impact parents' speech or child development in these communities. However, scarcity might still impact other aspects of cognitive functioning that have implications for parenting . Our results cannot speak to these possibilities. There is thus a need for further work examining whether and how resource scarcity relates to child-directed speech, and caregiving behaviors more broadly, in other socioeconomic and cultural contexts. One key limitation in the current study is that we did not collect any measures of household income or parent occupation, which have the potential to impact parents' child-directed speech. While some have argued that of SES indicators, parental education is most predictive of parents' speech 7 , others suggest that different SES indicators represent distinct constructs with unique linkages to parent outcomes and hence they should not be used interchangeably 73 . Therefore, future research examining how financial concern relates to parents' speech should test whether additional measures of SES interact with parental talk. A second limitation is that we lacked a direct measure of finances or financial concern. In the current study, we posited that it was financial strain specifically that contributed to time-dependent differences in parents' child directed speech. None of the participant characteristics in our data set varied with visit day except for a marginal difference in parent education, and our results held after controlling for that variable. It is possible that other factors that vary with time could have impacted parental language. However, Americans report that finances are their greatest source of stress 33 , and this source of stress seems the most likely to vary with the time of the month in which parent-child interactions occurred. We therefore conclude that financial concerns are the most probable factor that contributed to differences in parental language over the course of the month. Still, the effect sizes in the present study were modest, which could reflect our indirect measure of financial concern. Future research on this topic should include direct measures of perceived financial strain and family finances such as when parents were paid, whether families were receiving public assistance, or carrying debt. In addition to providing direct evidence for the impact of financial strain on parent talk, this might yield larger associations between financial concern and child-directed speech. However, collection of this information must be done with caution, as prior work has shown that priming parents to think and talk about financial concern results in reductions in their child-directed speech 53 . In conclusion, our study indicates that parents talk less to their children at later points in the month, when financial concern is likely to be greatest. Our findings thus suggest that efforts to improve child language outcomes might benefit from focusing on broader contextual factors, such as reducing parents' financial strain, rather than solely intervening on individual-level factors . The present study contributes to a growing body of evidence that financial strain impacts a range of parent and child behaviors [50][51][52][53] . Together, these findings suggest that reducing financial strain could have broad positive impacts on families, above and beyond enhancing child-directed speech and child language outcomes. --- Method Participants. This study drew on two existing corpora of parent-child interactions that were part of larger lab-based studies on children's social-cognitive development 74,75 . These corpora were selected because the same lab-based parent-child activity was used and both samples were socioeconomically diverse. The dyads in the two corpora were recruited from birth records provided by the California Department of Public Health and a database of parents living in Merced County, California who had previously expressed interest in participating in research studies with their children. Parents in the latter group were largely recruited at a variety of community events, many of which focused on providing resources and support for low-SES families. These procedures have been used in several prior studies to recruit socioeconomically and ethnically diverse samples 67,[76][77][78] . Dyads were recruited for a single lab visit and appointments were scheduled at parents' convenience. Timing of study visits over the course of the month was not controlled because this was not a factor of interest in the original studies. Parents were not paid for their participation; instead, all children received a small gift of approximately $5 value for participating. Dyads who met the following criteria were included in the present study: they completed the relevant parent-child interaction, children had no known speech, language, or developmental delays, and children were exposed to English at least 50% of the time. The final data set consisted of 166 parent-child dyads. Demographic information for this sample is provided in Table 1. The majority of children completed the tasks with their mother ; the remainder completed the tasks with their father . On average children were exposed to English 95% of the time . Over 95% of the sample heard English at least 75% of the time . Information on race, ethnicity, and socioeconomic status was obtained via parental report. Socioeconomic status can be accessed via a variety of indicators, including parents' education, occupation, and income 73,79,80 . These existing corpora did not include measures of family income or occupation, but did include a measure of parental education. As can be seen in Table 1, the highest degree completed by either parent was diverse, ranging from completing high school or less to possessing professional or advanced degrees, with a relatively even distribution across the education categories. Although income was not measured, the participants were drawn from a region where families are generally relatively low in socioeconomic status. The county where these participants were recruited has a poverty rate of 23% for children 18 years of age and under 81 , which is higher than both the state and national level . The median household income is also lower than those reported at the state and national level 81 . Procedure. Dyads participated in a single lab visit lasting less than 45 min; children completed one or more social cognition tasks and then dyads completed one or more interactive activities. The present study focused on a picture-book activity that was common across the two corpora. Dyads sat together in a chair or on the floor and viewed a wordless picture book that was adapted from prior research on parent-child mental-state talk 82 . The book contained color photos of children and adults engaged in a variety of activities . The pages did not contain any words. Parents were instructed to go through the book with their child as they would at home. Parents were allowed to use whichever language they felt most comfortable with. The experimenter then left the dyad alone to view the book; the interaction was video recorded. The length of the book and the duration of the activity varied across corpora. In one corpus 75 the book was 23 pages and parents were encouraged to take as much time as they wanted; in the other 74 , the book was 10 pages and parents were told that the experimenter would come back after 10 min to conclude the activity. For each interaction, parent language was transcribed verbatim by trained research assistants who used a formal protocol based on prior language research to guide their work 59,83 . To ensure accurate identification of words and utterances, all transcribers were trained to criterion before beginning the transcription process . Utterances were identified by grammatical closure, intonation, or pauses. Non-verbal sounds were not transcribed. Words that referred to sounds such as animal sounds were included in the transcription. Six parents spoke in Spanish for a portion of the task. For these parents, the interaction was first transcribed verbatim by a native Spanish-English bilingual transcriber, and then the Spanish words were translated into English. We then used the CLAN program 84 to calculate three measures for each parent: number of utterances, number of word tokens, and number of word types. Descriptive information for these variables appears in Table 2. We also calculated the total duration of each interaction. This was defined as the time between the onset of the first utterance about the book to the offset of the final utterance about the book. The average duration of the interactions was approximately 6 min . Despite differences in administration of the task, the duration of the interaction did not vary significantly across the two corpora , t = 0.96, p = 0.34. Only 10% of the interactions had durations longer than 10 min. --- Ethical approval. The right of the subjects who participated in our study were protected. The research was conducted in accordance with the Common Rule guidelines established by the US Office of Human Research Protections. The University of California Merced Institutional Review Board approved all procedures . All parents provided written informed consent prior to participation. --- Data availability All data generated or analyzed during this study are included in this published article . Received: 13 August 2021; Accepted: 18 May 2022 --- --- Competing interests The authors declare no competing interests.

Socioeconomic status predicts the quantity and nature of child-directed speech that parents produce. However, the mechanisms underlying this relationship remain unclear. This study investigated whether the cognitive load imposed by resource scarcity suppresses parent talk by examining timedependent variation in child-directed speech in a socioeconomically diverse sample. We predicted that child-directed speech would be lowest at the end of the month when Americans report the greatest financial strain. 166 parents and their 2.5 to 3-year-old children (80 female) participated in a picture-book activity; the number of utterances, word tokens, and word types used by parents were calculated. All three parent language measures were negatively correlated with the date of the month the activity took place, and this relationship did not vary with parental education. These findings suggest that above and beyond individual properties of parents, contextual factors such as financial concerns exert influence on how parents interact with their children. Research has shown that both the quantity and nature of child-directed speech is associated with numerous aspects of child development including receptive and expressive vocabulary development 1,2 , language processing abilities 3 , the lexical and syntactic diversity of the speech children produce 4 , and children's school readiness and academic success 5 . Given the broad body of evidence demonstrating the importance of child-directed speech, it is critical to identify potential sources of variability in parent talk. One factor that has received considerable attention is socioeconomic status (SES). Research suggests that parents of higher SES engage in higher rates of child-directed speech than lower SES parents [6][7][8] . The striking finding first published by Hart and Risley 6 showing large SES differences in child-directed speech became widely cited in popular press and academic journals and has since been described as the 30-million-word gap. Although there has been some recent debate regarding the nature of this 'word gap' 9-11 several recent meta-analyses have confirmed a relationship between SES and the quantity of language in children's environment 12,13 . In addition to this quantity difference, recent research has also shown SES differences in the nature of parents' child-directed speech. For instance, parents with higher SES use more diverse and sophisticated vocabulary and produce more complex sentences and syntactic structures than lower SES parents 2,4,7 . A question that follows is what might explain the relationship between SES and child-directed speech? One approach that has been taken to answering this question is to focus on properties of the individual parent. For instance, parents with higher levels of education (one dimension of SES) tend to be more knowledgeable about child development [14][15][16] . Research has in turn shown that parents with less knowledge or skills related to child development engage in less child-directed speech [16][17][18][19] and that the relationship between SES and child-directed speech is mediated by parenting knowledge 16,18 . However, there are several reasons to suspect that this individuallevel approach alone cannot fully explain SES differences in child-directed speech. First, interventions focused on enhancing parenting knowledge and skills are not always successful in increasing child-directed speech 20 . Second, mothers with high and low SES view child-directed speech as equally important, but still engage in child-directed speech at different rates 21 . Finally, some research has shown that there is considerable variability in child-directed speech within SES strata 4,7,8,22 , suggesting that there may be external effects on child-directed speech that operate across levels of SES.

Introduction of protective and risk variables. The development of mental health issues may be affected by both protective and risk factors. Both the presence and absence of risk and protective factors, as well as the various combinations of these two categories of variables, have an impact on the mental health of young people. Youth prevention and intervention efforts may benefit from a thorough analysis. To lessen the negative effects of risk factors, protective factors may be thought of as "characteristics at the biological, psychological, familial, or community level that are linked with a reduced chance of issue outcomes." On the other side, risk factors are "characteristics at the biological, psychological, familial, community, or cultural level that precede and are linked with a greater chance of negative consequences." In the table below, we see instances of youth, family, peer, community, and societal protective and risk factors. When you knowingly put yourself in harm's path, you run the chance of losing money or suffering some other negative outcome in the long run. Involvement in activities that put one at danger of bodily injury include examples of risk-taking behaviors including drinking and driving, binge drinking, self-harm, aggressive behavior, hazardous sex, cannabis usage, and risky sports. Teens and young adults are more likely to participate in dangerous behaviors despite their awareness of the risks involved. Behavior that involves taking risks is not unreasonable. Teenagers seem to have a heightened receptivity to novel and difficult input. Adolescents are particularly drawn to experiences that push them to their physical and mental limitations. Taking risks increases the likelihood of gaining social acceptability, confidence, and experience. Rather of trying to reduce risk-taking, we should instead aim to lessen the damage that results from it. --- Literature Review --- Kelly Wolfe et.al This research was out to disentangle the roles played by risk attitude, objective risk, and numeracy in explaining age variations in participants' propensity for taking risks during the recent coronavirus epidemic. We investigated if older and younger persons varied in their willingness to take health risks associated with coronaviruses, whether or not coronavirus risk, risk attitude, and numerical ability vary with age, and how these factors relate to one another. The research was observational, and individuals completed the measurements at random. Risk-taking, objective risk, risk attitude toward health and safety issues, mathematical ability, and risk perception in connection to the coronavirus were all reported by 469 participants. Our results suggest that younger persons take larger risks when it comes to coronaviruses, and that higher levels of numeracy play a mediating role here, but that objective risk and risk attitude play no role at all. Initial studies imply that changes in perceived risk between individuals of different ages contribute to the observed age-related disparities in coronavirus risk-taking. The results of this research may shed light on the question of whether disparities in risk-taking across age groups result from a natural decrease in capacities or from shifts in risk attitude during a pandemic. --- James Boylan et.al When we're bored, it's a catch-22 because we want to do something, but we don't want to do what's readily accessible. We are all experiencing this tension to varying degrees during this time of social isolation in reaction to the COVID-19 epidemic, and it is worsened when external causes put constraints on the variety of activities we may participate. We surveyed 924 people throughout North America using the online Mturk platform to see whether or not there was a correlation between self-reported boredom proneness and individual replies to questions concerning compliance with social-distancing criteria during the COVID-19 epidemic. Our sample supported recent findings in the study of boredom, such as an inverse association between boredom tendency and self-control. Also, We provide new evidence indicating those who are easily bored are more likely to take part in dangerous activities that put them at risk of being isolated from their peers. Moreover, we demonstrated that the tendency to grow bored quickly mediates the relationship between self-control and rule violation. According to these findings, susceptibility to boredom should be taken into account while trying to promote long-term social isolation. --- Takawira Munyaradzi Ndofirepi Little details concerning the mechanism by which entrepreneurship education and training influences its desired consequences are known, despite the common idea that educational opportunities like this help inspire future business owners. This study set out to answer the question, "Does education in entrepreneurship have a predictive connection with a person's desire to start their own business?" A cross-sectional survey of 308 pupils at a Zimbabwean vocational school allowed for this to be determined. Results show a favorable, statistically significant correlation between entrepreneurship education and achievement motivation, risk taking, a belief in one's own ability to influence events, and the ambition to start a business. Need for achievement, risk propensity, and an individual's sense of agency all contributed to a statistically significant variation in entrepreneurial ambitions. Only the drive for success acted as a mediator between the effects of entrepreneurship education on the intents of aspiring entrepreneurs and the other two personality traits. The results have important implications for the future of entrepreneurial education. --- David M. Lydon-Staley et.al Core to dual systems theories of adolescent risk taking are the concepts of sensation seeking and impulse control . Using information from the National Longitudinal Study of Adolescent to Adult Health, researchers analyzed the correlations between SS and IC and both current and lifetime smoking . Adolescence saw the largest correlation between SS and either current or past 30-day smoker status. The highest link between IC and smoking was shown in those in their mid-20s to early-30s, although it persisted regardless of age. The findings provide new light on the complex relationship between smoking and the many factors that make up dual systems models. Jens O. Zinn Today's civilizations are defined by their intense discussions and disputes about the pros and cons of taking risks . Unfortunately, efforts to minimize people's risk-taking via legislation and tactics typically fail, despite the availability of useful information. Professionals sometimes assume a lack of comprehension when they see the general public disregard sound counsel. Although this may be the case in many situations, a growing amount of evidence demonstrates that individuals frequently have adequate understanding while taking risks, rather than simple ignorance or misinformation. The complexity, dynamism, and paradoxes of human risk-taking are more understood thanks to the expanding corpus of study on the topic. Yet, there haven't been many efforts to organize this information. This page provides useful information for such an endeavor. It proposes differentiating between risk-taking incentives, degrees of control, and many sources of socially embedded reflexivity. Risk-taking is discussed in terms of its role in the formation and maintenance of a sense of self-worth. The paper concludes that individuals take risks in order to form and safeguard an identity they value, and that there is excellent evidence for the ways in which structural and cultural variables interact to affect risk-taking in a variety of contexts. Experts may learn more about risk and encourage individuals to take less of it if they take the greater social settings and individual risk behaviors of daily life into account. --- Methods --- --- Materials and Procedure Prior to any data collection, the appropriate internal review board ensured that the study's approach was in accordance with ethical norms. Each participant filled out the survey online to guarantee that everyone experienced the same style and procedure throughout the research. The redesigned DOSPERT's 30-item risk-taking subscale was administered, and participants were told that the research was exploring their perspectives on a wide range of life situations. The DOSPERT comprised six items total; two each for ethics, economics, health, leisure, and society. Attitudes toward risk in the social, recreational, and health domains were assessed independently from those toward risk in the financial, health, and leisure domains. On a scale from never to always, participants were asked how often they would engage in each activity. Responses were tallied across all six questions in each risk category, with higher scores indicating a more risk-taking disposition. --- Statistical Analysis Cronbach's alpha was used to assess the degree of dependability within each domain of the DOSPERT scale. Pearson r correlations were used to determine levels of intercorrelation on the DOSPERT scale. Ordinal data on participants' judgments of their comfort with various types of risk were analyzed using Friedman's analysis of variance , with the risk domain serving as a repeated measures factor. To examine if there is a correlation between age and risk taking, Participants' ratings of their own risk-taking behaviors were analyzed using multiple regression. There were two types of predictors used: age and gender, with an interaction term between the two included in the second stage. Model C is the result of replacing the interaction term with a quadratic term for age and then comparing the resulting R2 to that of Model A. Age, gender, age2, gender by age, and gender by age2 were all investigated as predictors in our fourth step of regression analysis [Model D]. This study showed no evidence of a statistically significant interaction between age and gender in any measure of risk-taking. Model C was run separately for men and women, and the R2 difference was compared to Model A on a gender-specific basis, if Model B's interaction term between age and gender was statistically significant. --- Results According to Table 1's Cronbach values, the DOSPERT scale has enough internal consistency dependability across all five risk categories. The intercorrelations for the DOSPERT scale are also included in Table 1. It was shown that the five risk areas were highly correlated with one another, with the exception of the ethical and social risk areas. Table 2 displays the average group's risk perceptions, which are greatest in the social realm , then according to their value as a source of fun , money , health , and morality . Our Friedman's ANOVA showed a significant impact of domain, 2 = 1026.07, p .001, which persisted even after we subtracted the significantly higher social evaluations, 2 = 177.01, p .001. Our research therefore supports the hypothesis that risk-taking varies by domain. After conducting a post hoc analysis with the Wilcoxon signed-rank test, we found that there were statistically significant differences in risk attitudes between the social and recreational domains , the recreational and financial domains , the financial and health domains , and the health and ethical domains . We've recently been concentrating on the disparity in risk-taking by age group. Table 3 displays the results of our tests for collinearity in each of our regression studies, which included examining the variance inflation factor and tolerance levels of each of our regression models. In the ethical, economical, health, and recreational realms but not the social realm, males were shown to exhibit much greater risk-taking attitudes than women. The individual causes of aberrant data were also looked at on a case-by-case basis. Standardized residuals, Cook's distance, average leverage, and the Mahalanobis distance let us identify an extreme case in the ethical domain, and we have since removed it from all of our analyses. In Table 2 we see that men and women had different risk attitudes on average, with the biggest gap in the financial area and the smallest gap in the social domain --- A Typology Of Risk Here, risks are analyzed from an individual perspective and characterized as potential dangers to health. Happiness may be measured in several ways. It includes not only material safety but also personal safety, community safety, and financial stability. Health in the full sense of the word, including mental, physical, social, and spiritual well-being, is also included. Pathologies in the home, such physical and sexual abuse, and in the community, like being a victim of crime, pose serious risks to people's well-being and safety. Some, like smoking, drinking, and risky behavior, are the result of individual decisions on how to live one's life. There is a complex web of relationships between health, happiness, and social variables including housing, employment, and income, as shown by the high rates of injury and sickness that I attribute to lifestyle choices. The state of well-being is the end outcome of several, interconnected factors in the actual world. Using information from recent studies conducted in New Zealand, Table 4 categorizes and identifies key risks to young people's health and safety, noting whether men or girls are more at risk or whether the risk impacts both sexes to varying degrees. Pregnancy and other issues that solely affect one gender are not included in the table. --- Table 4 Adolescent Risks -Gender Differences Conclusion Age-related variations in risk-taking were investigated in this research. Nonetheless, there are a variety of ways to take risks. Although some theories attribute risk-taking behaviors to a lack of self-control, others provide explanations based on sensation-seeking and impulsivity. Taking risks is probably a complex concept, especially within certain types of risks. Risk-taking may be heavily influenced by one's ability to handle emotions, and this ability evolves throughout life. There may be changes in the way different age groups approach risk-taking activities since older individuals show a preference for positive information at the expense of negative information. Hence, investigating gender variations in behavior and sensitivity to risk factors is a promising field for future study, with an emphasis on the youth and their families. This should include considerations beyond gender, such as socioeconomic and racial background. Recent attention has been focused on disparities between the sexes in terms of academic success and completion rates.

Our results suggest that risk-taking inclinations in the financial sphere decline dramatically with older age. In contrast, social risk-taking increases somewhat between the ages of 18 and 24, then declines considerably in later life, whereas the decline in risk-taking for recreational purposes is steeper between the ages of 18 and 24 than in later life. Taking risks with one's health and one's morals tends to decrease significantly with age. Later in life, men, but not women, lowered their financial risk-taking significantly, whereas women reduced their social risk-taking more substantially than men did. "Risk variables" are thought to predispose a person or group to some bad consequence and consequently to constitute a danger to wellbeing. These elements may be human qualities or environmental ones, inherent in the family, community, school or peer group environment.

Introduction The COVID-19 pandemic and its social distancing measures have resulted in dramatic changes to working life for many sectors and roles. These include job insecurity, job loss, job changes, and/or reduced control over job roles and responsibilities as organisations pivot to different business models . Due to national lockdowns and other pandemic restrictions, many individuals who typically worked in offices or other communal settings had to rapidly switch to teleworking from home. Despite the general flexibilities offered by telework, the sudden shift to extreme teleworking in newly-created home offices likely led to new and intense strains in job roles, in the physical working environments and in the social context at home. These sudden changes required new or different levels of resources and pose a likely risk to occupational health, such as work fatigue. Work fatigue is central to job burnout theories model, conservation of resources theory; Hobfoll, 1989;Maslach et al., 1997;Demerouti et al., 2001;Shirom, 2003). Job burnout theories describe an energy depletion-protection/renewal process through job demands and job resources. Demands require sustained effort that depletes energy, resulting in emotional, cognitive/ mental, and physical work fatigue, whereas resources can protect or renew energy. Interest in the drivers and consequences of work fatigue has risen in recent decades given its links to employee health, motivation, and performance . Work fatigue and burnout research during the pandemic has predominantly focused on specific occupations such as frontline healthcare workers and teachers as the pandemic has placed considerable psychological strain on members of these professions. Increasing attention is, however, being given to teleworker fatigue and burnout . Although relationships between job demands, job resources, and work fatigue in a non-pandemic context are established, some emerging evidence suggests that prior knowledge cannot be readily transferred, since pandemic working poses new issues and intensifies existing issues . Furthermore, the impact of relevant job resources, such as job control and job change management, appears underexplored in pandemic teleworking research. Teleworking research during the pandemic has mostly examined the blurred lines between job and private domains, specifically childcare, and health consequences such as work fatigue . Comparatively little research has considered the impact of the physical teleworking environment on work fatigue. However, as pandemic research indicates, homeworking environments varied drastically across countries and sectors , resulting in privacy-related issues and risking teleworkers' health. Lack of privacy is a huge health and performance concern in office research . We focus in this study on work privacy fit, which is rooted in Person-Environment fit theory and describes the congruence between the desired and the actual level of work privacy. Work privacy is defined as a socio-environmental control process of information and social stimuli in the work environment. Workers attempt to achieve the best possible fit between their actual and desired levels of input/stimuli from their colleagues and output they make to their colleagues. As outlined in the privacy fit theory, work-and health-related outcomes can be maximised if environmental characteristics can be organised in a way that supports individual privacy needs . However, work privacy fit and its predictors during pandemic teleworking has been almost neglected. As pre-pandemic and pandemic studies have indicated separate relationships between job demands and job resources, the home office environment, privacy-related issues, childcare, and work fatigue, our study examined relationships together between these factors during the first COVID-19 lockdown in 2020. Our study makes three key contributions to the existing literature: 1. Examines the relationship between the physical environment and privacy fit. 2. Examines the relative effect of psychosocial , environmental , and social working conditions on work fatigue. 3. Examines the interaction between environmental and social working conditions and work fatigue. The conceptual model of our study is presented in Figure 1. Overarching theoretical approach: socio-ecological framework We examine psychosocial, environmental, and social teleworking conditions during lockdown and their relationship to work fatigue through the theoretical lens of the socio-ecological framework on work context . This theory-based framework suggests that health at work is influenced by factors across four nested levels: individual determinants; social environments; built environments; and 10.3389/fpsyg.2023.1155118 Frontiers in Psychology 03 frontiersin.org structural environments. In this study we examined how factors across the levels of this framework influence work fatigue. We also examined interactions between these factors. Starting at the fourth, outer level, the framework proposes that health at work is influenced by structural factors, such as job design and teleworking policies. We examined the role of psychosocial working conditions during lockdown telework as structural factors. At the third level, health is influenced by the built environment and its adequacy to meet individuals' work needs. We examined aspects of the home office as built environment factors. At the second level, health is influenced by the social network that operates within an environment. We examined social family presence when teleworking, specifically childcare duties, as a social environment factor. Finally, as health is also influenced by individuals' demographic characteristics, we included age and gender as individual-level control variables. We also included country of residence during lockdown as a structural-level control variable. --- Structural environment factors: psychosocial teleworking conditions and work fatigue Job demands are job conditions that require sustained effort, for example workload and responsibilities, and are often the most important predictor of work fatigue/burnout within the COR and JDR models . Studies have found links between high job demands/workload during the pandemic and work efficiency/ productivity perceptions, or higher work engagement . In these pandemic studies, links are mostly found when home environments had minimal distractions/interruptions and were workconducive . Presumably, in a pandemic context high job demand can also act as a motivational driving force under the right circumstances, as shown in pre-pandemic research . However, a different stream of pandemic research indicates that job demands have changed in nature and intensity due to new pandemic-specific job demands, such as teleworking-specific tasks , disruptive teleworking management tasks and telework never seeming to end . High levels of job demand during pandemic telework have been associated with increased perception of stress , emotional work exhaustion/fatigue , and burnout , especially when adequate job resources were not in place and when compared to pre-pandemic work . Job control is defined as the perceived level of autonomy and influence workers have over when and how they work; e.g., autonomy in scheduling work, making decisions, and choosing working methods . Pre-pandemic teleworking research indicates that teleworking is predominantly advantageous for job control, with teleworking enhancing perceived job control in terms of when and where work is done and how it fits around other aspects of life . In pre-pandemic research, job control is consistently positively associated with wellbeing and negatively associated with indicators of burnout, including work fatigue . However, there is still little evidence on the salience of this association in the pandemic teleworking context as studies have not tested associations with a global operationalisation of work fatigue but with related constructs such as emotional fatigue , non-workspecific exhaustion , and wellbeing (Straus et al --- 2022) . Furthermore, studies suggest that prior knowledge cannot be readily transferred as pandemic working poses new issues -such as daily COVID-19 task setbacks -and/or intensified old issues, such as family-work-interference . Job change captures how well any organisational change is managed and communicated . Organisational change, which may include changes to one's own job, is associated with work fatigue/exhaustion and burnout . Good management of organisational or job change, e.g., high-quality supervisor, peer support, or providing training, is a resource that can help employees cope with change-related stress and therefore avoid work fatigue . Since teleworkers often have reduced opportunities for support and feedback from colleagues they are at risk of negative outcomes arising from job change. This risk was accelerated by the fast organisational changes due to the pandemic ; a large number of workers were suddenly primarily teleworking, a shift that organisations and employees were largely unprepared for with more than half of workers in European Union countries having had no prior experience with teleworking . Nonetheless, very few studies investigated the role of job change in the pandemic teleworking experience. Some longitudinal evidence suggests that being satisfied with organisational communication about COVID-19 related work changes is an important resource to protect wellbeing during pandemic teleworking . However, overall, the role of perceived job change management in work fatigue during pandemic teleworking has been rather neglected despite researchers having called for it . In terms of the structural environment, this study contributes to emerging evidence about pandemic telework by exploring relationships between job demands, job resources and work fatigue during the first COVID-19 lockdowns in 2020. We propose that: H1: Individuals reporting higher job demand, lower job control and poorer job change management during the COVID-19 lockdown will report greater work fatigue after controlling for all other predictors. --- Built environment factors: privacy fit, home-office characteristics, and work fatigue Work privacy fit 1 addresses the home office from a socio-spatial level to determine its adequacy to fulfil work privacy needs . Work privacy fit is a multidimensional conceptualisation and operationalisation of work privacy, which 1 There is a conceptual and psychometric difference between privacy fit and work-privacy/privacy-work interference; the latter refers to work-family/familywork interference . builds on Altman's privacy regulation framework that is related to Person-Environment fit theory . As such, work privacy is regarded as "a control process of input and output of information and social stimuli in the work environment. Workers attempt to regulate stimuli coming from their colleagues and output they make to their colleagues. Workers strive to achieve the best possible fit between their actual and desired levels of input and output" . Four distinct dimensions of work privacy are considered: "distractions , interruptions , task privacy and conversation privacy " . For further detail on the conceptual underpinning of work privacy, please refer to Weber et al. . Congruent with Person-Environment fit principles, it is possible to maximize work-and health-related outcomes if environmental characteristics can be organised in a way that supports individual privacy needs . Pre-pandemic research indicates that work privacy fit in an office context drastically shapes the work experience, as it is associated with various work-related , and occupational health outcomes, such as work fatigue . Most pandemic studies on privacy fit or privacy-related aspects have explored the impact on work efficiency and performance perceptions . Few studies have considered the relative effects of privacy fit on health and wellbeing. Those that do have concentrated on reduction of sleeping problems and musculoskeletal complaints when privacy was given. Studies that focused on occupational health have only observed aspects that were related to poor privacy fit . These studies indicated negative associations with overall stress , mood , dimensions of burnout , and multiple aspects of mental health . However, none of the studies distinctly assessed the relationship between all dimensions of privacy fit and all dimensions of work fatigue . In this study, we examined work privacy fit as a factor in the built environment and examined its relationship to work fatigue during lockdown teleworking. We propose that: H2: Individuals reporting higher levels of work privacy fit will report lower levels of work fatigue during the COVID-19 lockdown after controlling for all other predictors. Home office characteristics as predictors of privacy fit: Pandemic research indicates drastic differences in home office environments supporting or hindering privacy across samples. Some experienced privacy-related advantages, such as less distractions/interruptions, that were related to increases in concentration and productivity . Others reported Frontiers in Psychology 05 frontiersin.org problems with privacy, distraction, or interruptions since pandemic teleworking . Considering the acknowledged impact of privacy fit on occupational health, likely predictors of privacy fit ought to be explored. Based on pre-pandemic and pandemic evidence, this study focuses on three key predictors of privacy fit: shared/unshared workspace, perceived noise levels, and crowding. Pandemic research indicates that unshared workspaces at home were associated with fewer non-work interruptions or distractions , perceived workspace suitability or perceived performance loss . Similarly, perceived social density/crowding or number of people at home while teleworking was related to lack of privacy , disturbances or perceived workspace suitability . As evident from pre-pandemic research, household size can make it difficult to regulate social interactions and achieve good privacy fit , and the availability of an unshared room for work has been positioned as critical success factor for telework . Further, perceived noise exposure was related to perceived home-office distractions , workspace suitability, and perceived performance loss . To further understand the impact of the built environment during lockdown teleworking, we examined how home office characteristics affected privacy fit. We propose that: H3: Individuals reporting more noise, more crowding, and who work with others in the same room will report lower work privacy fit during the COVID-19 lockdown after controlling for all other predictors. --- Social environment factors: childcare responsibilities, privacy fit and work fatigue Telework is promoted as a way to reduce work-family conflict because it allows flexibility of time management and reduces the need to commute between different locations . However, this flexibility can also have negative impacts on boundaries between professional and domestic spheres . For women, family appears more likely to intrude into work time whereas for men telework may be seen as an opportunity to work for longer or in a more focused way . Where work already conflicts with family demands, intensive teleworking from home has long been positioned to lead to interference between the two, ultimately increasing work fatigue . In the context of nursery and school closures as a result of COVID-19 lockdowns, many parents had to combine full-time work with childcare and education in their home environment. Emerging empirical evidence indicates this has resulted in reduction of work efficiency, high self-reported loneliness, anxiety, depression, psychological distress, and overall reduced physical and mental wellbeing among parents, especially among mothers , and increased the risk for parental burnout 2 . The presence of and number of children, work-home conflict, home-to-work interference, and home demand have also been associated with emotional fatigue , job burnout , non-work specific exhaustion , and reduced physical and mental health . These are made worse in combination with low levels of family-to-work facilitation , low social support , low job control, and low partner support . In terms of the social environment, this study contributes to emerging evidence about pandemic telework by exploring the relationship between childcare and work fatigue during lockdown. We propose that: H4: Childcare responsibilities will be positively related to work fatigue during the COVID-19 lockdown, after controlling for all other predictors. Privacy fit as a mediator: a considerable number of studies indicate incremental links between some, or all, of the following variables: childcare responsibilities; privacy/distractions/ interruptions; work-family/family-work interference/conflict; fatigue/wellbeing . These links appeared particularly pronounced or are hypothesised to be, when the home environment did not cater for spatial separation but forced individuals to share the work room with household members . For example, Leroy et al. showed relationships between non-work responsibilities , shared/unshared workspace at home, number of non-work interruptions, and emotional exhaustion. Childcare responsibilities predicted more interruptions whereas dedicated workspace predicted fewer interruptions; in turn, interruptions predicted emotional exhaustion. As such, we suggest that a significant amount of variance in the relationship of childcare on work fatigue is explained by privacy fit. To further understand the impact of the social and built environment during lockdown teleworking, we therefore examined the potential for privacy fit to explain any relationship between childcare and work fatigue. We propose that: H5: Privacy fit will mediate the relationship between childcare responsibilities and work fatigue during the COVID-19 lockdown after controlling for all other predictors. 2 There is a conceptual and psychometric difference between parental burnout and job burnout . We included gender, age, and country as control variables, as research suggests they may influence experiences of pandemic teleworking. For example, women have reported to be experiencing more fragmented time whilst pandemic teleworking due to familyhome interference and as such, gender-related differences in privacy fit are likely. Gender differences have also been reported in mental health whilst teleworking and in pre-pandemic work fatigue research . Regarding age, studies have indicated age-related differences in pandemic working experiences . Country variation has been observed in teleworking preparedness with regards to equipment and home office environments and there were also country differences in terms of strictness of social distancing measures and other restrictions during COVID-19 lockdowns. --- Methods --- Study design and procedure An online, cross-sectional survey using the platform 'Limesurvey' was conducted with an opportunistic sample of workers, recruited mostly in three primary countries associated with the research group: Germany, Switzerland, and the United Kingdom. Participants were also recruited from other countries . The survey was administered in English as a key measure was only available in English at the time. Given the particular limitations of conducting research during the pandemic, this also helped to reduce the procedural complexity of data collection. The survey launched on April 10th 2020, when lockdown or strict social distancing measures had been in place between 18 and 26 days across the primary countries . Data were collected until May 2nd 2020. Participants were recruited via social media and email among the researchers' extended networks of colleagues, friends, and family. Inclusion criteria were that during the previous 2 weeks of the COVID-19 lockdown participants: were aged 18 years or older, were working and had primarily worked from home. A subset of the data has been analysed and reported in a previous study, which examined the role of work privacy fit, job demand, job control, and job change in predicting future teleworking intentions . --- Participants and ethics Ethical review and approval were not required for the study on human participants in accordance with local legislation and institutional requirements. Participants were given the option to particate voluntarily and were required to provide written informed consent if they agreed to be in the study. All survey data were anonymised to make it impossible to gather any identifying information. Data were shared only among the research team and all data were stored on a secure university server. Data collection procedures and data use were undertaken carefully so as to conform with the Swiss Federal Data Protection Act. As the COVID-19 lockdown was for some a stressful life-event, a debrief page was provided to participants. This was specific to each of the three primary countries and provided links to healthcare providers and other sources of available online support. A total of 737 respondents participated, of which 258 were excluded in the first data cleaning step due to extensive missing data or illogical responses suggesting non-valid submission of responses. This resulted in a sample of 479 respondents which included some missing data. A total of 99 cases had missing data among individual items of the study variables . Little 's Missing Completely at Random Test on all ordinally scaled study variables suggests it is unlikely for there to be systematically missing data = 62.16, p = 0.65) and is congruent with listwise deletion. As a second data cleaning step, all cases with missing data on the study variables were deleted listwise resulting in a final sample of 380 respondents. In the final data cleaning step, all cases that indicated a 'not applicable' response on job demand, job control and job change items were excluded from the analysis. The final data set comprises n = 300. Participation by primary country was almost evenly distributed ; 17.4% of responses stemmed from 'other countries' . The gender distribution among participants was uneven; almost two times more females than males took part. The majority of participants fell in the age groups 21-30 , 31-40 , and 41-50 . Approximately a third of the sample reported to have childcare responsibilities while pandemic teleworking. However, 32.0% reported that between one to four children under the age of 15 years 3 were present at home. As such, not all participants who had children present when teleworking had caretaking responsibility; this discrepancy was only present in responses from males. Regarding teleworking arrangements before the pandemic, 43.0% had teleworked from home before, on average at a ratio of 33.3% per week. During the pandemic, participants worked on average 35.57 h per week at home, which was for 42.0% of participants about the same as before the pandemic . The majority of participants stated that their working pattern has changed during pandemic teleworking. 3 The age limit of 15 years was deemed appropriate as the age of legal responsibility and liability as well as maturity concerning various aspects ranges between 14 and 16 years in the primary countries . Hence, it was assumed that children from the age of 15 years onwards would require less supervision than younger children. Regarding participants' home office environment, 18.3% had a dedicated home office, 57.6% worked either on reallocated furniture or a dedicated desk in a room also used for other purposes . Overall, the median number of people present at home when home working was 3 . If others were also working from home, 71.6% worked in separate rooms in relation to the participants; 28.4% shared their room or their work area . Detailed participant demographics and home office information are provided in Table 1. --- Measures Measures are described below. Descriptive statistics and correlations are provided in Table 2. --- Demographics Data were collected on age, gender, country of residence during previous 2 weeks of lockdown, number of children aged under 15 years, and childcare responsibilities . Information about teleworking was also collected, including teleworking start date, prior teleworking arrangements and the percentage of time teleworking pre-lockdown, hours per week worked, whether they had worked more or less since the pandemic, and if they had changed their work pattern during pandemic teleworking. Country and gender categories were dummy coded with 'other countries' and 'male' being the referent. Structural environment factors: psychosocial teleworking conditions Job demand, job control, and job change were assessed by the short version of the Health and Safety Executive indicator tool . The dimensions job demand and job control were each measured by four items. Job change was measured with three items . Items were measured on a 5-point Likert scale, ranging from 1 to 5 . The answer option N/A was added to account for those participants who were self-employed. N/A responses were discounted for the analysis. Internal consistency for all three dimensions was acceptable . Mean composite scores were calculated. High scores reflect high levels of job demand, job control, and job change. Built environment factors: home office characteristics , and work privacy fit Perceived noise and crowding were measured with one item each . Participants were asked to rate if the home office 'felt crowded' , and if 'it was noisy ' . Items were measured on a 5-point Likert scale, ranging from 1 to 5 . High scores reflect high levels of perceived noise and crowding. The own work location in the house/flat over the past 2 weeks was assessed with five categories ; and other . The first four categories were dummy coded, with 'other' being the referent. Other home-workers' primary work location in relation to the participant was assessed with three categories . A fourth category was included , to reflect participants who were not sharing their home with other homeworkers. As with the previous dummy coding, the first three categories were dummy coded with 'NA -no other teleworkers' being the referent. Work privacy fit was measured using a simplified version of Weber Privacy at Work inventory. Participants rated their satisfaction with the level of privacy they experience at work based on the importance of four separate dimensions of privacy assessment: conversation privacy / working without being overheard, task privacy / working without being overseen , working without being interrupted, and working without distractions. Explicitly, the items for satisfaction were: 'I was satisfied with the time I could work without being overheard'; 'I had the opportunity to work without others listening into my work or non-work related conversations when I wanted to' 'I was satisfied with the time I could work without being overseen'; 'I had the opportunity to work without others seeing me or my work when I wanted to' . 'I was satisfied with the time I could work without being interrupted'; 'I had the opportunity to work without engaging with anyone in my home when I wanted to' . 'I was satisfied with the time I could work without visual and acoustical distractions'; 'I had the opportunity to work in a quiet and visually calm environment in my home when I wanted to' . Items were measured on a 5-point Likert scale, ranging from -2 to 2 . Internal consistency for privacy satisfaction and privacy importance was adequate . A composite score to reflect relative privacy fit was created by weighting privacy satisfaction ratings with privacy importance ratings using multiplication . High scores reflect high levels of work privacy fit. --- Social environment factors: childcare responsibilities Childcare responsibilities were measured using a single item as part of the demographics section of the survey. Participants were asked whether they had to look after their children in addition to working from home; they could answer 'yes' or 'no. These categories were dummy coded with 'no childcare' being the referent. --- Work fatigue Work fatigue was assessed using an 18-item measure by Frone and Tidwell on a five-point Likert scale ranging from never to every day. This three-dimensional work fatigue inventory takes into account three different resource-specific types of fatigue at work: emotional fatigue, mental fatigue, and physical fatigue . An overall fatigue mean composite score across all dimensions was calculated. The wording was amended to suit the study by using a reference frame of the last 2 weeks as opposed to the original reference frame of 12 months. Internal consistency was excellent . High scores reflect high levels of work fatigue. --- Data analysis The statistical software package R version 4.2.2 was used to compute descriptive statistics and correlation matrices. We used Pearson correlations where both variables were continuous, tetrachoric correlations between two dichotomous variables, and point-biserial correlations between a dichotomous and continuous variable. The lavaan package and semTools package in R were used to test the path model and indirect effects using the MLM estimator as per Hypotheses 1-5. The default confidence intervals from the lavaan package were used. --- Results The proposed model had a good fit with their robust estimators , with chi-square not being significant. An overview of the final model, with details of direct relationships between variables is shown in Figure 2. Of the control variables , only gender predicted work fatigue; females were more likely to report greater levels of work fatigue. H1 was partially supported, as higher job demands predicted higher levels of work fatigue. However, neither job control nor job change predicted work fatigue as we had hypothesised. Congruent with H2, individuals' levels of work privacy negatively predicted their levels of work fatigue during the COVID-19 lockdown; those who reported poorer work privacy experienced greater work fatigue. Figure 2 and Table 3 show partial support for H3, where noise and crowding both negatively predicted work privacy fit during COVID-19 lockdown. Noisier and more crowded home-working spaces were associated with poorer work privacy fit. Contrary to our hypothesis, however, if and how workspace was shared during lockdown teleworking did not predict privacy fit. No support was found for H4, as childcare responsibilities did not directly predict work fatigue; however, in line with H5, an indirect relationship was observed between childcare responsibilities and work fatigue with work privacy fit being a significant mediator . Those with childcare responsibilities experienced greater work fatigue, as a result of experiencing poorer work privacy fit. A post-hoc power analysis showed that a sample size of n = 300 yields a power of 73% to reject a wrong model with an amount of misspecification corresponding to RMSEA = 0.03 on alpha = 0.05. This is below the recommended threshold of 80% suggesting a slightly underpowered model. However, given the concern around post-hoc power testing , the primary implication is recognizing the need for a larger study sample in future studies and the importance of power testing in the study design period. --- Discussion This cross-sectional study examined predictors of work fatigue during home-based teleworking in the first COVID-19 lockdown, by 10.3389/fpsyg.2023.1155118 Frontiers in Psychology 10 frontiersin.org examining the influence of various factors across different levels of a social-ecological model of occupational health . Work fatigue was influenced by factors from the structural/psychosocial, built, and social environmental levels, and at the individual level . On average, our sample was only moderately work fatigued; they experienced work fatigue around once a week in the 2 weeks prior to participation. Women were more fatigued than men, which confirms previous pandemic and pre-pandemic evidence . However, these results should be interpreted with caution due to study limitations hindering the estimation of robust effects. Furthermore, we recognise that, despite the challenges associated with the sudden transition to teleworking, those workers who were able to predominantly or exclusively telework during the early stages of the COVID-19 pandemic may well have experienced lower levels of job insecurity, psychological distress, physical health issues, and fear of the SARS-CoV-2 virus than workers who continued working on-site throughout lockdowns and other restrictions . With regards to work fatigue predictors, we found two predictors in our dataset. The first and strongest predictor -job demands -was at the structural/psychosocial level. Other variables at this level were not significantly associated with work fatigue in our sample. The second strongest predictorwork privacy fit -was at the built environment level. Also at the built environment level, the variables noise and crowding perceptions were significant predictors of privacy fit but shared/unshared workspace was not associated with work fatigue. The social environment level predictor -childcare -did not predict work fatigue directly. Instead, childcare responsibilities had an indirect effect on the likelihood of teleworkers experiencing work fatigue, and this association was positively mediated by privacy fit. To provide an in-depth discussion of the associations observed, each result is discussed by its socioecological level. --- Structural environment factors: psychosocial teleworking conditions Our results show that job demand levels were low and job control and job change were rather high in our sample. We observed a positive association between job demands and work fatigue, which is theoretically consistent , and reflects findings from other pandemic studies indicating work fatigue-related effects . However, overall, pandemic studies have indicated that the experience of job demands and associated impacts varies drastically across samples. Some studies identified additional, pandemic-specific job demands impacting teleworkers' mental health . In contrast, other teleworkers, mostly in work-conducive built environment conditions, experienced high demands alongside a sense of higher productivity and engagement . This heterogenic picture is at least partially related to differences in sectors, jobs and related teleworking readiness. However, the varying experiences are also likely related to differences in the home environment and social life domain. For example, if teleworkers experience low levels of socio-environmental stress ; if they can regulate social contact at home; and if they do not have children or care responsibilities, they are more likely to have the ability to recover from the strain of high job demand. In this scenario, high levels of job demand can act as a motivational factor . Apart from permanent contextual factors , varying levels and results of job demands across pandemic studies should also be interpreted in the context of when data were collected. Workload levels were dynamic during COVID-19, following a U-shape time trend; longitudinal data shows a dip in workload in March 2020 when pandemic lockdowns first occurred, followed by a steady increase from April to May 2020 ; our results from April 2020 could fit this pattern. It seems likely that once pandemic-related changes decreased and practical problems at the start of pandemic teleworking were resolved, people resumed their work and projects started again, leading to rising workload in May . The high level of job control also aligns with levels and time trends from other longitudinal studies. For example, Syrek et al. suggest control increased from February 2020 onwards. It appears that workers experienced new levels of control and responsibility over their own work time when switching to pandemic telework. However, we failed to detect any effects of job resource variables on work fatigue. This could be explained by small effect sizes and underpowered tests, as job resources are acknowledged to be weaker predictors of work fatigue . Other pandemic studies could not detect known mitigation effects of job control on the relationship between work-family-interference and mental health ; work-family-interference was positioned as too extreme to be mitigable. Similarly, the undetected effects of job control, our test for a job change-work fatigue association might have been underpowered. This notion is supported by pandemic evidence indicating that job change takes a subordinate role in explaining wellbeing-related phenomena, such as work engagement/vigour, when compared to other psychosocial job aspects such as job control or relationships during the pandemic . Further, our assessment might have had more validity if we had adapted items and made the link to COVID-19-related job change management more apparent; we employed the standard items of the assessment. In fact, other studies that made the link explicit indicated wellbeing effects of good communication regarding COVID-19-related job changes . Overall, this suggests the relationship between job demands and resources are complex during pandemic teleworking and warrants a systematic analysis of pandemic evidence by considering data collection timepoints. --- Built environment factors: privacy fit and home office characteristics On average our sample had positive privacy fit scores with a slightly negatively skewed distribution, which means that many were able to meet their work privacy needs at home. Those that had good privacy fit in terms of distractions, interruptions, task, and conversation privacy had significantly lower work fatigue levels. This lockdown-specific result is unsurprising given the body of evidence regarding the health effects of unsuccessful spatial regulation of social interaction . Therefore, our study supports previous hints at privacy fit-exhaustion associations that used elements of the privacy concept and complements emerging pandemic evidence of privacy's role in mental and physical health issues ). Furthermore, this result adds to the substantive body of evidence on the link between stress/fatigue/exhaustion, anthropomorphic noise and interruptions from prior to the pandemic. Noise from other people and interruptions represent two of four dimensions of the work privacy fit conceptualisation. However, work privacy fit, as tested here, also considers output controls, specifically task and conversation privacy. Therefore, the identified effect of work privacy fit on work fatigue broadens our understanding of social and environmental stressors and their impact on work fatigue. As such, our study adds to growing evidence that providing workers with the ability to regulate social interactions can influence occupational health. With regards to work privacy fit predictors, our results only identified noise and crowding perception to be significant, whereas the type of workspace or the type of sharing in the workspace were not significant. Our study variables had each been identified in prior studies to relate to aspects of privacy, such as disturbances . Pandemic research also indicates direct relationships -not via privacy -between these home office characteristics and health/wellbeing, such as psychological distress . This is not surprising since noise and crowding are acknowledged socio-environmental stressors which can have various work-relevant consequences on cognition , behaviour , and affect , and can pose a risk to health , which is similar to the attributes of privacy. However, the lack of any observed effects regarding the "objective" predictors in our study might be explained by underpowered test statistics, the fact that almost 72% of participants were able to work in a separate room , and possibly too much shared variance between the objective characteristics of the environment and the perceptions of noise and crowding . Further, from a theoretical perspective, it ought to be mentioned that certain privacy conceptualisations treat crowding perceptions as an outcome of poor privacy whereas others treat it as a predictor . Indisputably, there is a significant overlap between privacy and crowding which are both transactional socioenvironmental appraisals of the environmental condition. Thus, both relationships could be true depending on the underlying conceptualisations of crowding and privacy used. In conjunction with other pandemic evidence, this study suggests that the possibility for withdrawal from crowded household situations can most likely help employees to protect their energy depletion, recovery process, and work focus. Qualitative accounts of other pandemic studies found that common rooms, such as the kitchen and living room, were permanently used by many as an alternative workspace, which clearly does not provide adequate withdrawal possibilities . Indeed, the availability of a private room for work and a workplace that is workconducive have been positioned as critical success factors for telework . Beyond obvious predictors of privacy, such as a private room, privacy appraisal can also be influenced by more nuanced aspects in the environment. Those can include personalization of spaces and other appropriation behaviours . By appropriating a space, workers change the meaning of a space according to their interests and "claim" the space . Space-claiming creates territories/boundaries of social and environmental control which in turn is an acknowledged moderator for socioenvironmental and environmental stress . This is exemplified by office studies showing moderation effects of personalization on perceived privacy and emotional fatigue . Overall, privacy fit appraisal appears to be less related to the actual design of work environments and to depend more on psychological factors, such as control . --- Social factor: childcare and its link to privacy fit and work fatigue In our sample, approximately 30% reported having childcare responsibilities while teleworking. However, caring for children had an indirect effect on work fatigue in our study, whereas other pandemic studies identified direct effects . However, we found a positive indirect effect of childcare responsibilities on work fatigue through privacy fit, i.e., having childcare responsibilities negatively impacted privacy fit in homeworking spaces, which resulted in increased work fatigue. Given that privacy fit appraisal appears to be highly related to environmental control , it is likely that teleworkers with childcare responsibilities not only experience more privacy violations but foremost feel less in control over their physical environment and social regulation possibilities. Further, we found that work fatigue was particularly pronounced in women. Overall, this corresponds with other pandemic evidence about people with children at home while home-working; those with a caretaking role experienced more fragmented time with more interruptions, and in turn, were more exhausted , especially when family/partner support and family-to-work facilitation was lacking . In this regard, qualitative pandemic evidence provided rich insights into pandemic workers' lives . They have portrayed workers who live with children as having no opportunity to withdraw due to space-sharing during working hours or switching work locations in the home. For example, during family dinner time when the dining table was used as workspace. Finding places that are quiet and free of clutter has been described as difficult for those with small children . Further, echoing Frontiers in Psychology 13 frontiersin.org prior pandemic evidence , in the present study, women appeared particularly burdened during the pandemic with pre-pandemic acknowledged differences of home-work intrusion and associated fatigue intensifying during pandemic conditions. An illustrative example is provided by Meyer et al. study which indicated a curvilinear relationship between pandemic duration and non-work specific exhaustion in women. Exhaustion intensified during the beginning of the pandemic when childcare was not available, whereas exhaustion reduced when lockdown measures were eased. Partner support lessened the effect. In contrast, the exhaustion of men who worked from home and/or did not take care of children was minimally affected by the pandemic. --- Limitations The present research is subject to several limitations. The first pertains to representativeness which is undermined by using convenience sampling and possible participation/self-selection bias, as only those workers with the capacity to be part of the study or who were dissatisfied with pandemic telework might have participated. As the lockdown posed new and intense challenges, it is possible that study participation was not possible for those struggling the most. Hence, our study might underestimate the negative impact of teleworking during lockdown. Further, the sample is not representative for the entire teleworking population in the primary countries ; neither is the sample representative across any specific occupational groups or sectors. The study registration was public, therefore anyone interested was able to participate which likely brings a broad distribution and diversity of occupational sectors and roles. However, owing to the rapid onset of the pandemic and our attempt to start data collection quickly, we recognise that we had overlooked to collect more occupational specific data such as type of sector, occupation, job role, or tasks. This information would be advantageous since across these factors, workers may differ in their experiences of teleworking, alongside their teleworking infrastructure and home office setup before and during the pandemic . Since countries worldwide introduced different containment measures during the crisis, it is likely that occupations are differently affected by the coronavirus pandemic and the results should be interpreted against this background. Thus, the impact of the forced transition to telework observed in our data may be more pronounced in certain occupations that are less accustomed to teleworking. Additionally, this could be further pronounced in countries with lower levels of digitalisation or in countries with less developed teleworking initiatives than those primarily observed in this study. The second limitation pertains to the cross-sectional design of the study, which examined variables at a single moment in time, prevents causal inferences and is susceptible to common method bias . However, given the rapid onset of the pandemic and the fast-moving pace of lockdowns being implemented early in 2020, we had limitations in terms of time and resource to plan and conduct a study with more advanced study design. As emerging pandemic research shows Straus et al. and Syrek et al. , it proves valuable to observe the relationships between psychosocial, social, and occupational health variables longitudinally as the pandemic teleworking context is dynamic in which organisations and individuals adapt to the unprecedented changes to working life. Further, although testing the mediation effect with a cross-sectional sample is appropriate , it still has significant limitations. Cross-sectional mediation analyses carry the risk of misrepresentation of psychological processes and ambiguity of the direction of the effect; longitudinal mediation models provide better representations of mediation processes . In addition, the low sample size has power implications, particularly as some key dummy variables were low in frequency. Therefore, the potential causal relationships identified in this study should be interpreted with caution and examined further using longitudinal designs and with larger sample sizes. In addition, relative importance analysis could be used in future studies to test for the relative importance of each predictor in relation to the presence or absence of other predictors. The third limitation pertains to the socio-ecological framework. It provides a useful lens through which to investigate the relationship between health outcomes and individual, social, environmental, and work factors, but it is possible that specific factors on each of these levels were unduly represented in our study. For this reason, further research that adopts a fuller reflection of all levels is warranted. This could explore data that have not been present in research to date, relating to, e.g., sectors, occupations, company size, self-employment, job tasks or job roles. It is predicted that when these factors are acknowledged, workers' teleworking infrastructure may differ, alongside workers' experiences of teleworking. Additionally, wider aspects of the social environment were not recorded in this study beyond a focus on family commitments. Study of the wider social environment could include support systems from co-workers, managers , and family . Furthermore, on the individual level, individuals' traits and abilities, such as introversion/extroversion or sensory sensitivity, could be linked to differences in work fatigue levels as research has shown that people who are introverted or sensory sensitive are more quickly aroused and disturbed by environmental and socio-environmental stressors . Further studies could examine these factors in more detail and identify suitable traits for intervention targets. A full investigation of the context levels was beyond the scope of this study. Lastly, since a considerable amount of cross-sectional pandemic research did not discuss the context of time in relation to data collection within the pandemic , it was difficult to position our findings within the current pandemic literature. As evident from longitudinal studies, demands and resources were highly Frontiers in Psychology 14 frontiersin.org dynamic with nurseries and schools closing and re-opening , and some teleworkers and organisations appeared to have achieved better management of the multiple demands on various context levels . As such, we hope that future pandemic research can further contextualise the aspect of time when presenting their findings. --- Conclusion Our study offers insight into the impact of the first lockdown of the COVID-19 pandemic on employees' occupational health. In line with existing knowledge, the psychosocial factor job demand was the strongest predictor of work fatigue. Our study also underlines the emerging importance of privacy fit and its predictors in the home office environment as well as its influence on one's likelihood to experience work fatigue. The results also indicate that women were more fatigued than men and that childcare responsibilities became problematic when optimal privacy fit was not provided. Further, it shows the different capabilities of teleworkers for post-pandemic teleworking due to differing home office conditions. As such, this study offers a multi-contextual approach to the investigation of work fatigue and can inform strategies on how to best implement teleworking post-pandemic. This can help to ensure that any future, more permanent changes to teleworking policies include the physical environment and are supportive of employees and organisations. --- Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- Ethics statement Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. --- --- --- Publisher's note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Background: During national lockdowns in response to the COVID-19 pandemic, previously office-based workers who transitioned to home-based teleworking faced additional demands (e.g., childcare, inadequate homeworking spaces) likely resulting in poor work privacy fit. Previous office research suggests poor work privacy fit is associated with lower wellbeing and higher work fatigue. Emerging evidence suggests a relationship between childcare duties during pandemic teleworking and work fatigue. In addition to psychosocial working conditions (job demand, job control, and job change management), which are acknowledged predictors of work fatigue, this poses a significant threat to occupational health during pandemic teleworking. However, the relative effects of aspects of the psychosocial environment (job demands and resources), the home office environment (including privacy fit), and the social environment (childcare) on work fatigue as well as their interactions are under-explored. Objective: This study examined the relationships between the psychosocial, environmental, and social working conditions of teleworking during the first COVID-19 lockdown and work fatigue. Specifically, the study examined teleworkers' physical work environment (e.g., if and how home office space is shared, crowding, and noise perceptions) as predictors of privacy fit and the relationship between privacy fit, childcare, psychosocial working conditions (job demand, job control, and job change management), and work fatigue. Work privacy fit was hypothesized to mediate the relationship between childcare and work fatigue. Methods: An online cross-sectional survey was conducted with teleworkers (n = 300) during the first COVID-19 lockdown in April and May 2020; most participants were in Germany, Switzerland, and the United Kingdom. Results: Path analysis was used to examine the hypothesized relationships. Privacy fit was lower for those reporting greater levels of noise in home-working spaces and those feeling crowded at home. Work fatigue was lower amongst those with greater privacy fit and higher amongst those with high levels of job demand. An indirect relationship was observed between childcare and work fatigue with privacy fit mediating this relationship.

Background With global economic integration, international and intranational migration is common [1]. Economic reform in China and the transition to a market economy resulting in massive internal migration as workers were allowed to move from rural areas to the economically productive areas. Eastern and coastal regions in the Pearl River Delta including Shenzhen were major destinations for migrants from impoverished western and central inland areas of China. The nationwide internal migrant population reached 0.26 billion in 2010 [2]. According to the National Seventh Population Census, approximately 70% of resident population in Shenzhen are mobile people [3]. Migrants are at the bottom of the social ladder and are discriminated against, have a high prevalence of mental health problems, and have experienced a high incidence of suicide [4]. Suicide accounts for approximately 800,000 global deaths each year and is a serious global public health problem that needs to be addressed [5]. The World Health Organization estimates that the suicide rate in 2016 was 10.6 per 100,000 people, with 80% of these suicides occurring in low-and middleincome countries [6]. Death by suicide additionally produces a profound emotional impact on bereaved loved ones [7,8]. Understanding the causes of suicide, and best practices for assessing, preventing, and treating suicidal behavior, has been identified as a key public health priority and global imperative [9,10] The Interpersonal Theory of Suicide proposes that suicide occurs with two constructs, namely the acquired capacity for lethal self-injury and the desire to die, neither of which alone is sufficient to cause an individual to die by suicide [11,12]. The most dangerous form of suicidal ideation is caused by the simultaneous presence of two interpersonal constructs-thwarted belongingness and perceived burdensomeness . TB describes the unmet need of being socially integrated, and PB reflects the perception of being a burden for others [13]. The Interpersonal Needs Questionnaire was developed to assess the main constructs of the IPTS for predicting suicidal desire [14]. The factor structure of the INQ has been validated by many researchers and among different populations [15][16][17][18][19][20][21][22]. However, results have been inconsistent, with most studies validating a better model fit for the two dimensions of the INQ [18,[23][24][25][26], and some studies validating a better model fit for the three dimensions of the INQ [27]. Currently, most studies on suicide focus on students [28][29][30][31] and depressed patients [32][33][34], and few studies have been conducted on migrant industrial workers, whose population reached 174 million in 2019, which was an important feature of China's economic development [1]. Surveys have shown that 14.7% of migrant workers are at high risk of mental illness and may perceive unmet interpersonal needs, which are considered proximate and causal factors for suicidal thoughts and behaviors [35]. One study estimated that from 2015 to 2017, the annual suicide rate among migrant workers in Zhongshan, China was 4.46/100,000, slightly higher than the city average [36]. The successive incidents of suicides and deaths of migrant workers have drawn particular attention to the psychological conditions of young migrant workers on the production line [4]. In past studies, there have been several versions of the INQ, including 10-, 12-, 15-, and 25-item questionnaires [14,24,26,37,38], whereas Hill et al. recommended using the 15-or 10-item versions because these versions indicated the most consistent model fit in confirmatory factor analyses [39]. In this study, we primarily used the INQ-15 recommended by the Van Orden K.A. [14]. The aim of this study was to validate the reliability and validity of the INQ-15 among industrial workers in Shenzhen, China, thereby informing the application of the INQ-15 and indeed IPTS theory to the Chinese population. To this end, a series of exploratory factor analysis , confirmatory factor analysis , measurement methodology framework of the Item Response Theory , logistic regression analysis, and receiver operating characteristic analyses were conducted. While the structure of the INQ has been confirmed on a solid theoretical basis by Van Orden et al. [14], we believe that it is crucial to validate the translated version in the Chinese population and that the results may vary. Following factor analysis, we examined the psychometric properties of the TB and PB and their related constructs by comparing them and examining whether they accurately predicted suicidal ideation or whether one of the constructs had better predictive power. --- Method --- Participants and Procedures A cross-sectional survey of industrial workers in Shenzhen was conducted from October to December 2019. A stratified multi-stage sampling method was used for recruitment from 16 factories and 513,215 industrial workers. Assuming a prevalence of past-year suicidal ideation in migrant workers of 15% [18,33,34], using α of 0.05, and a relative error for sampling of 0.1, we calculated a required sample size of 1533 to allow for a non-response rate of 50%. First, 16 factories, including 4 machinery processing factories, 3 electronic device manufacturing factories, 3 printing and dyeing factories, 2 chemical material factories, 1 smelting factory, 1 garment factory, 1 food and beverage manufacturing factory, and 1 other factory were randomly selected. Full-time employees aged ≥18 years in 3 to 4 workshops from each factory were then randomly invited to participate in a survey conducted at the Longhua District Center for Disease Control and Prevention . Each participant signed a written informed consent and was informed of the potential benefits and risks of participating by trained fieldworkers before the survey. Since the questionnaire contained questions about their mental health, the researcher provided respondents with assurance of anonymity during the survey, the right to quit at any time, and that there would be no consequences for refusing the survey. Each participant who spent approximately 30 min to complete a survey in a private room would be compensated with a USD 2.60 cash voucher. A group of two public health researchers, an epidemiologist, a health psychologist, a health communication expert, and a factory worker designed the questionnaire. Twenty workers were invited to participate in a pilot study under the instruction of trained researchers. Some reading and comprehension problems were recorded in the process and the questionnaire was revised and finalized based on their feedback. These 20 workers did not participate in the final survey. --- Instruments and Measures The study collected sociodemographic information on workers' age, gender, place of origin, monthly income, living alone or not, and time staying in Shenzhen, and used the following self-reporting tools. --- Chinese Version of the Interpersonal Needs Questionnaire-15 The 15-item INQ, a self-report scale, published by Van Orden K.A. [14] and translated by Cao [35], was used to measure thwarted belongingness and perceived burdensomeness. Previous research on the two-dimensional INQ-15 scale has shown that the first six items measure perceived burdensomeness and the last nine items measure thwarted belongingness. Participants were asked to indicate how true each item had recently become for them. A 7-point Likert scale was used, ranging from "not true for me at all" to "very true for me". Six items on the TB scale were reverse scored and total scores were coded, with higher scores reflecting greater perceived burdensomeness or thwarted belonging. The INQ-15 has been shown to predict suicidal ideation [13]. The subscales have demonstrated good internal consistency, with Cronbach's alpha values ranging from 0.85 to 0.90 for PB, and 0.81 to 0.87 for TB [39,40]. --- The Suicidal Ideation Scale The suicidal ideation scale consists of three questions: "Have you considered suicide in the past year?"; "Have you planned suicide in the past year?"; and "Have you committed or almost committed suicide in the past year?". In this study, anyone who answered "yes" to any of these three questions was considered to be at risk of suicide. A previous study has shown that single-item assessments of suicidal ideation are significantly associated with total suicidal ideation scores from multiple assessments [41]. --- Ethics Approval The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of School of Public Health, Sun Yat-sen University . --- Data Analysis All completed questionnaires were recorded by two people via Epidata . Means and standard deviations are reported for normally distributed data. A review of kurtosis and skewness indicated that INQ-15 scores were not normally distributed; therefore, non-parametric tests and medians are reported throughout the analysis. Exploratory factor analysis and confirmatory factor analysis were conducted using Mplus 8 . Robust maximum likelihood estimators robust to non-normal data [42] and oblique rotations allowing for correlation of the examined factors [42] were applied. The IRT allows one to maintain only those items that contribute unique variance in the measured construct, making it possible to provide more precise psychometric understanding of each item's contribution to an overall mean score [43]. Data screening and regression analyses were performed using SPSS version 25 . To assess the accuracy of the INQ-15 total score and subscale scores in predicting suicidal ideation, receiver operating characteristic analyses were conducted. Several fit indices were considered, since each index of model fit has unique properties that give rise to strengths and weaknesses: two absolute fit indices, the chi-square and the standardized root-mean-square residual ; two comparative fit indices, the comparative fit index and the Tucker-Lewis index ; and a parsimoniouscorrected fit index for root-mean-square error of approximation . All fit statistics were associated with the MLR estimator of Mplus, and the reported chi-square was the Yuan-Bentler chi-square [41]. CFI and TLI values > 0.90 and RMSEA and SRMR values < 0.08 were identified as acceptable model fit metrics in this study [44,45]. --- Results Of 2700 workers selected, 2023 completed a self-administered questionnaire. The response rate was 75%. Since we focused on migrant workers, local workers and those who did not report their homeland were excluded. Eventually 1805 migrant workers were included, as shown in Figure 1. The participant age range was from 18 to 61, the mean age was 32.50 , and 67.3% of them were male. All participants were randomly split in two groups with equal numbers. The first group including 874 workers was used for exploratory factor analysis. The mean age was 32.43 and 67.6% of them were male. The confirmatory factor analysis was conducted on the second group including 931 workers with a mean age of 32.56 who were 66.9% male. Descriptive statistics and intercorrelations of the INQ items for all participants are presented in Table 1 andFigure Descriptive statistics and intercorrelations of the INQ items for all participants are presented in Table 1 and Figure 2. The result of the Shapiro-Wilk test suggested that responses of the 15 INQ items were not normally distributed. Therefore, estimators of robust to non-normality were used. --- Factor Structure of the Interpersonal Need Questionnaire --- The Exploratory Factor Analysis As expected, multiple items of the INQ were skewed positively, implying that the INQ measured non-normally distributed. Most items especially those of the same factor were significantly correlated, supporting appropriate internal consistencies, except for item 1/2 with item 13, item 3/4 with item 14 and item 15, and item 5 with item 13. The results of the exploratory factor analysis 1-4, as displayed in Table 2, showed that the three-factor and four-factor model demonstrated better model fits. However, the factor loading of a three-factor model had better indicators for each item than four-factor model. The pattern of loadings for this model in Sample 1 indicated that the first six items and items 9/11/12 clearly loaded onto a "PB" factor, which means the three items written to measure thwarted belongingness cross-loaded onto perceived burdensomeness. Items 7/8/10 loaded onto thwarted belongingness, a "TB" factor, and the last three items strongly loaded on a third factor, which we named "social isolation", an "SI" factor. The oblique rotated loadings for three-factor model are showed in Table 3. --- Factor Structure of the Interpersonal Need Questionnaire --- The Exploratory Factor Analysis As expected, multiple items of the INQ were skewed positively, implying that the INQ measured non-normally distributed. Most items especially those of the same factor were significantly correlated, supporting appropriate internal consistencies, except for item 1/2 with item 13, item 3/4 with item 14 and item 15, and item 5 with item 13. The results of the exploratory factor analysis 1-4, as displayed in Table 2, showed that the three-factor and four-factor model demonstrated better model fits. However, the factor loading of a three-factor model had better indicators for each item than four-factor model. The pattern of loadings for this model in Sample 1 indicated that the first six items and items 9/11/12 clearly loaded onto a "PB" factor, which means the three items written to measure thwarted belongingness cross-loaded onto perceived burdensomeness. Items 7/8/10 loaded onto thwarted belongingness, a "TB" factor, and the last three items strongly loaded on a third factor, which we named "social isolation", an "SI" factor. The oblique rotated loadings for three-factor model are showed in Table 3. These days, I have at least one satisfying interaction every day 0.855 * * significant at 5% level. --- The Confirmatory Factor Analysis Fit statistics for the CFA in Sample 2 are presented in Table 2. The fit statistics for original three-factor model in Sample 2 did not meet the acceptable criteria proposed before. Therefore, the model was refined according to the modification index. The inclusion of residual correlations between the items 1 and 2 and between the items 11 and 12 improved the fit of the model clearly, as shown in Table 3. The values of both RMSEA and SRMR were below 0.08. In addition, the CFI and TLI values exceeded the cutoff score of 0.90, supporting a good model fit. The χ 2 value was still significant and the χ 2 /df value was still higher than acceptable level. However, the χ 2 value has been constantly criticized for its sensitivity to sample size [46] as the χ 2 value will always be significant, resulting in the rejection of the model fit in large samples. Due to the controversy, the χ 2 value was given less attention when it conflicted with other model fit indices. Estimated parameters for the refined model are presented in Table 4. All items loaded onto the anticipated latent variable significantly with R 2 ranging from 0.13 to 0.81. Along with the model fit indices, parameter estimates supported the three-factor model of the INQ-15. There was a positive correlation between the "SI" and the "TB" factor but negative correlations between the "PB" and "TB" or "SI" factor. --- IRT Modeling and M2 Test The RMSEA of the M2 test of the model was <0.001, which was far below 0.08, while the p-value was 0.74, indicating good model fit of the IRT modeling. --- Predictive Validity of the INQ Logistic regression analysis showed that the total scores of the INQ predicted suicidal ideation, with an OR = 1.084 , after controlling for sociodemographic characteristics. For our data, the self-reported rate of suicidal ideation was 3.4%, and using the INQ-15 summed item scores to assess suicidal ideation produced an AUC = 0.733 , as shown in Figure 3. Contrary to other studies [16,21] only the main effect of PB proved to be valid, with an OR = 1.094 and with an AUC of 0.786 . In addition, the comparison of the predictive ability between the INQ total scores and PB scores was significant with p < 0.05. The cut-offs were 53 for the INQ score and 18 for the PB score . --- Discussion This study aimed to validate the Chinese version of the Interpersonal Needs Questionnaire-15 among industrial workers and comprehensively test the association of interpersonal needs with suicidal ideation. Even though a growing number of studies have used the INQ to examine the applicability of the Interpersonal Psychological Theory of Suicide, as well as to examine its validity in different countries and various populations [17,22,24,26,27,29,38,39,47,48], the application of IPTS and INQ among Chinese people is rare [49,50]. Considering the collectivistic culture in China and the difference of INQ across cultures [51], we reasoned it was necessary to validate the INQ in a sample of industrial workers, whose suicide events caused great social attention in the past years. The result of exploratory factor analysis showed a three-factor model demonstrated better model fit and factor loading, which is different from most existing studies [14,19,21,51]. As the INQ-15 was developed as an English language instrument for measuring interpersonal needs, cultural adaptation should be considered. Yeonsoo Park et. al.'s results implied that the reading of an item, and ultimately the experience of specific psychological states, can vary depending on cultural influence [16]. In a Slovene translation and validation study, the researchers chose to omit items loaded weakly on its hypothesized factor and reduced INQ 15 to INQ 12 [47]. However, Quintin A. Hunt et al. extracted a third factor of perceived isolation "PI", formed from the TB factors instead of omitting them in a sample of clinically depressed and suicidal youth [27]. Meanwhile, it is also worth noting that most industrial workers in Shenzhen come from different cities and float around across the country. Most of their friends and social connections are in their hometown and people they work with are thus unfamiliar. So, it is possible that social isolation may exist if a specific population are removed from their living environment. --- Discussion This study aimed to validate the Chinese version of the Interpersonal Needs Questionnaire-15 among industrial workers and comprehensively test the association of interpersonal needs with suicidal ideation. Even though a growing number of studies have used the INQ to examine the applicability of the Interpersonal Psychological Theory of Suicide, as well as to examine its validity in different countries and various populations [17,22,24,26,27,29,38,39,47,48], the application of IPTS and INQ among Chinese people is rare [49,50]. Considering the collectivistic culture in China and the difference of INQ across cultures [51], we reasoned it was necessary to validate the INQ in a sample of industrial workers, whose suicide events caused great social attention in the past years. The result of exploratory factor analysis showed a three-factor model demonstrated better model fit and factor loading, which is different from most existing studies [14,19,21,51]. As the INQ-15 was developed as an English language instrument for measuring interpersonal needs, cultural adaptation should be considered. Yeonsoo Park et. al.'s results implied that the reading of an item, and ultimately the experience of specific psychological states, can vary depending on cultural influence [16]. In a Slovene translation and validation study, the researchers chose to omit items loaded weakly on its hypothesized factor and reduced INQ 15 to INQ 12 [47]. However, Quintin A. Hunt et al. extracted a third factor of perceived isolation "PI", formed from the TB factors instead of omitting them in a sample of clinically depressed and suicidal youth [27]. Meanwhile, it is also worth noting that most industrial workers in Shenzhen come from different cities and float around across the country. Most of their friends and social connections are in their hometown and people they work with are thus unfamiliar. So, it is possible that social isolation may exist if a specific population are removed from their living environment. The CFA confirmed that perceived burdensomeness, thwarted belongingness, and social isolation are distinct but related, with thwarted belongingness and social isolation being closely related. The initial model demonstrated poor fit. However, when allowing two pairs of items to covary, the fit indices improved to excellent. Items 1 and 2 refer to the positive effects of an individual's death on others; items 11 and 12 refer to the relationship between the self and outsiders. Because each pair shared a common theme, we reasoned that allowing the pair of items to covary would be acceptable just like other research [17,52]. The IRT modeling and M2 test approved the procedure. In our study, the TB was significantly negatively associated with PB and positively correlated with SI, and we interpreted such relationships to be due to the difficulty participants may have had dealing with reverse-coded questions. In line with the interpersonal-psychological theory of suicidal behavior [12], the results of the current study suggest that the INQ strongly predicts desire for suicide. As socioeconomic factors including relative income [53,54] have been associated with suicidal behaviors, we re-ran a regression analysis to identify a unique contribution of INQ to suicidal ideation and the relation was still significant. Meanwhile, the effect of PB and TB was significant, before and after controlling for demographic characteristics. These results are in accordance with the theory, which assumes that all constructs are needed in order for suicidal ideation to develop [11,14], and the findings of some previous studies also support it [13,55]. Consistent with Mitchell et al. [56] and Jeffrey B. Brookings et al.'s findings, the results of the ROC analysis indicate that the INQ-15 may be useful and PB may be better in detecting suicidal ideation among individuals. Individuals whose INQ scores exceeded 53 or PB scores exceeded 18 may be at high risk of suicidal ideation and in need of help. In this study, a hotline number was given to all workers in case they needed psychological counseling. However, the INQ-15 was not developed as a screening tool. It was thus difficult to apply cut-off scores to measure suicidal ideation in reality. Limitations of this study are that it focuses on migrant workers in Shenzhen only and that we did not repeat the survey to get the test-retest reliability; thus, the findings cannot be generalized to average populations in China. However, we did use a larger sample in our study, so the results may provide a worthy reference for the application of INQ-15 in large-sample population surveys. Second, since the culture effect has been demonstrated [16,51] and the Chinese version of INQ-15 was used in this study, the culture effect and translation influence were not tested. Third, the three questions measured short-time suicidal ideation rather than life-time suicidal ideation. However, the mean time the investigated workers were staying in Shenzhen was 6.24 years , so it was reasonable for the INQ to predict short-time suicidal ideation. --- Conclusions In conclusion, the INQ has good psychometric properties and can be used to assess how industrial workers living in the Shenzhen perceive meeting interpersonal psychological needs. To our knowledge, it is the first study to validate the Chinese version of INQ-15 in a sample consisting of migrant workers, and the validation of the scale among migrants is the first step necessary to test the interpersonal-psychological theory of suicide on a specific population. The translated INQ confirmed three distinguishable and internally consistent factors corresponding to PB, TB, and SI, and predicted suicidal ideation properly. Future studies may seek to develop norms or cut-off scores at which elevated scores on the INQ-Chinese would indicate an elevated risk for suicide and focus on interventions in this process to prevent suicide. --- Data Availability Statement: Data are available on request due to privacy and ethical restrictions. The data presented in this study are available on request from the corresponding author. The data are not publicly available due to protection of participants' privacy. ---

Objective: Interpersonal theories of suicide suggest that the Interpersonal Needs Questionnaire (INQ) can be used to measure suicidal ideation, but few studies have focused on migrant people, a group with a high prevalence of suicidal ideation. The aim of this study was to validate the psychometric properties of the INQ-15 and its prediction of suicidal ideation among migrant industrial workers in China. Method: A stratified multi-stage sample of 2023 industrial workers was recruited from 16 factories in Shenzhen, China. There were 1805 nonlocal workers, which we defined as migrant workers with a mean age of 32.50 ± 8.43 years old who were 67.3% male. The structure of the Chinese version of the INQ-15 and its correlation and predictive utility for suicidal ideation were examined through factor analysis, the Item Response Theory, the M2 test, logistic regression, and receiver operating characteristic (ROC) analysis. Results: Different from studies among various samples in which a two-factor solution is identified, results within this sample indicated three factors: perceived burdensomeness, thwarted belongingness, and social isolation. The model fit statistics of three-factor INQ were 0.075 for RMSEA, 0.945 for CFI, 0.932 for TLI, and 0.067 for SRMR. The model standard estimated factor loadings ranged from 0.366 to 0.869. The summed scores of INQ and perceived burdensomeness predicted suicidal ideation after controlling for sociodemographic characteristics such as age, gender, and income with AUC of 0.733 (95% CI: 0.712/0.754) and 0.786 (95% CI: 0.766/0.804). In the meantime, the comparison of the predictive ability between INQ total scores and PB scores was significant with p < 0.05. Conclusion: The INQ has good psychometric properties and can be used to assess how migrant workers living in the Shenzhen perceive meeting interpersonal psychological needs and shows good predictive ability of suicidal ideation. Perceived burdensomeness appears to play a role in suicide and may be a point of intervention, yet the notable deviation from previous findings and the relative weakness of two of the other factors warrant further study.

Background In Regina's North Central neighbourhood, issues of addiction continue to jeopardize the parenting roles of First Nations mothers. Residents of this neighbourhood frequently encounter poverty, injection drug use and domestic violenceall of which affect their caregiving ability. In one support program offered to residents of the neighbourhood, breastfeeding re-established the caregiving role of mothers. In the 1980s, a young First Nations population moved to Regina, Canada, looking for a new life, away from their culture and its traditions [1]. At this time, however, Regina had a burgeoning drug market with a sex-trade industry and gang affiliations to support it. With little support for positive lifestyle choices, many of the youth succumbed to a lifestyle of drug and alcohol use. This lifestyle continues for many within the population today, and has a profound affect on their parenting ability. In 2010, a review of the province's child welfare system identified that 80% of children in government care were of First Nations descent, a population that makes up only 10% of the province's population [2]. A national survey of human immunodeficiency virus cases further identified that the number of cases in North Central Regina were three times greater per capita than anywhere else in the country; 92% were associated with IDU and 69% were associated with First Nations ancestry [3]. Healthiest Babies Possible Program , a prenatal/ postpartum support program in North Central Regina provides support to, on average, half of the neighbourhood's expectant mothers. The program, set up by First Nations women in the community, brought support to mothers with caregiving roles. An increased focus on breastfeeding became a part of the program when the Baby-Friendly Initiative , a program promoted by the health region, was introduced. The BFI has been a part of the World Health Organization health action to support breastfeeding world-wide, particularly in emergent situations. In HBPP, commitment to breastfeeding was further strengthened with the recognition of breastfeeding as a part of women's life-giving role in First Nation's beliefs, recognized to promote a caregiving relationship for the mother with her infant. These beliefs also link mothers to the cosmic realm for ancestral support in this relationship with breastfeeding [4]. HBPP participants experienced empowerment effects from breastfeeding, which in turn significantly enhanced perceived ability to care for their infants in other activities. As self-confidence for caregiving increased, drug and alcohol use stopped. Realizing the power of breastfeeding to increase an overall sense of caregiving-empowerment, HBPP staff and participants set out to measure this effect to further promote mothers' breastfeeding opportunity, not always supported by healthcare providers. --- First nations breastfeeding practice Caregiving was historically significant for women in First Nations tribes and included the kill of small game, planting of crops, care of children and childrearing that included teaching children traditional values [4][5][6]. The teepee, has been used as a symbol of mothers in this role. The poles are seen to be in the shape of a woman; and the buffalo skin like a shawl wrapped around her . The family is often shown inside the teepee further recognizing the mother's protective role for her family [5]. Infants were kept in the constant watch of their mothers who carried them in a moss bag, secured to their backs. Keeping infants in this proximity encouraged the motherbaby relationship and promoted breast milk supplies. Fathers encouraged a high quality of breast milk by providing mothers with the best cuts of their "kill." Other women in the tribe supported breastfeeding by assisting with the care of older children or breastfeeding an infant when the biological mother could not. This was done when Chief Crazy Horse, a memorable First Nations chief from the Lakota tribe, was orphaned as a young child. In addition to this support, older women, known as "Kohkoms," assisted mothers with their knowledge of herbal remedies, such as the topical use of balsam to relieve engorged breasts [6,7]. Fig. 1 Written permission for the illustration "The Red Tipi" was provided by the artist Holle Hahn for use in this document, November 11, 2019 Impact of Western society on first nations breastfeeding Many First Nations people lost traditional cultural practices as a result of colonization and changes enforced by the Indian Act in 1876 [4,8]. When land designation went to males instead of females, family roles were dismantled and the females' leadership role for caregiving was undermined. First Nations food sources became food rations provided by colonizers, creating dependency by First Nations for their daily existence. Indian Agents, sent out by colonizers, enforced the use of milk powder for infants, thereby implying a mothers' milk was substandard. In a review of the Canadian National Database for Breastfeeding, a drop in Indian and Inuit populations' breastfeeding was observed from 1960 to 1980 [9]. Early in the 1960s, breastfeeding rates were 69.4%, significantly higher than the 38% reported for the general population at that time. By 1980, breastfeeding rates had dropped to less than 60% in the Indian and Inuit population while the rates in the general population rose to 76%. A lower percentage of women breastfeeding within these populations continues today [10]. Traditional caregiving practices and support for breastfeeding came under new scrutiny when government workers were brought onto reserves to monitor mothers' caregiving in the 1960s. Not fully understanding how the First Nations mothers' caregiving had been devastated by colonization, First Nations women were portrayed by the workers "as demanding, filthy and prone to drunkenness." [4] Government workers relocated many children far away from their homes, placing them in government foster care or residential schools in an action referred to as the Big Scoop [1]. It was this action that brought young people to Regina, seeking a sense of identity that fit with Western society and a life they believed to be better than what they would have remaining on their reserve. Ultimately, this move created devastation for the youth and their lives. --- Empowering mothers caregiving in disadvantaged circumstances Research underlines the value of accomplishments with caregiving to create a positive self-worth by mothers dealing with disadvantaged circumstances, such as being adolescent, having low income or education, and marginalization in society [4,11]. Positive affiliations with families and peers for caregiving are important to support caregiving practices such as breastfeeding. In one study, relocation of mothers from rural communities in India to urban Mumbai slums showed increased autonomy with caregiving despite continued partner abuse and isolation by their culture's class system [12]. The change was linked to increased peer contacts and as well as observation of other mothers' autonomy by social media. This led to increased responsibility for families' healthcare, lifestyles and some income. Locklin [13] noted an enhanced sense of self in the caregiving role for a small group of mothers from Hispanic descent with successful breastfeeding experiences. The mothers, who were multiparous, had attempted breastfeeding in the past, but discontinued prior to three weeks postpartum. With this experience, weekly support for breastfeeding was provided by peers who assisted the breastfeeding practise. Mothers became strong enthusiasts for breastfeeding, empowered by their breastfeeding success. Evaluations of the empowerment effect were limited, however, to self-reporting at a four-month postpartum interview. A study conducted by Mossman, Heaman, Dennis, &. Morris [14] found adolescents who breastfed had increased self-worth, believing themselves to be valuable family members and having more confidence in social groups, enhanced by a sense of self following breastfeeding success. Evaluation of these indicators was at 28 days postpartum. First Nations mothers identified in the study were two times less likely to initiate breastfeeding as compared to other mothers, possibly related to a decreased sense of self with caregiving. Epstein [15], a research psychologist and breastfeeding activist, recognizes the value of a positive sense of self for mothers with breastfeeding. She credits the breastfeeding relationship between a mother and her infant to her ability to re-frame negative images of herself into positive ones. Caregiving accomplishments, as with breastfeeding, are recognized as significant to promote mothers' caregiving roles, particularly when disadvantaged. --- Methods While associations between positive self-images and caregiving functioning have been made in other Western research, a strong association between breastfeeding and its capacity to promote caregiving in high-risk situations has not yet been evaluated. The realization that breastfeeding empowered HBPP mothers to be stronger caregivers of their infants, identified by infant feeding, caregiving assessment and participation, emotional support, and follow up of infant health, created interest by the researcher to measure this effect. Commitment to measuring confidence with breastfeeding following the promotion of breastfeeding in the program was shared by mothers in HBPP. It was linked by some to their first real experience of unconditional love in a relationship. The goal for the study was to empirically measure the correlation between breastfeeding and the mothers' caregiving association while faced with challenges such as their own lack of role-modelling with this care, lack of resources and lifestyle risks. Both HBPP staff and participants recognized the value of such a measurement to support mothers' breastfeeding opportunity, often challenged by healthcare providers and government workers. A longitudinal study design measuring caregiving indicators before and after breastfeeding, as well as when mothers did not breastfeed, was possible given mothers participation in HBPP until six months postpartum. The intent of the study was to establish breastfeeding as a catalyst for caregiving and a lifestyle free from drug and alcohol use. Indicators of empowerment observed with breastfeeding included increased self-esteem, more participation in infant care and cessation of drug and alcohol use. Kabeer [16] recognizes such achievements to indicate an on-going empowerment process for caregiving when positive beliefs about caregiving ability are recognized by the mother. As achievements continue, these beliefs become deep-rooted, having a synergistic effect for confidence to assume additional activities with caregiving. --- Selection and description of population All HBPP participants were invited to participate in the study over a six-month period. Most begin participation at around 16-20 weeks gestation. Expectant mothers more than 28 weeks gestation were excluded from participation due to the influence of elevated prolactin occurring by this time. Increased prolactin hormone levels and decreased activation of hypothalamic-pituitary-adrenal axis occurring with breastfeeding decreases the mother's usual stress response potentiating her connection with the infant to enhance caregiving [17,18]. Another variable promoting accurate measurement of empowerment indicators was the homogeneity of the group. Prenatal and postnatal support for breastfeeding was similar for study participants given their participation in HBPP. As well, participants came from the same neighbourhood and were dealing with similar disadvantages related to their First Nations ancestry and the undermining of cultural beliefs and practices by Western society. Concern regarding mothers' drug or alcohol use during infant care was monitored as a part of their HBPP participation. Interaction for this also prepared mothers for cessation of drug and alcohol use. Continued support by HBPP workers in the postpartum period allowed mothers' lifestyle choices to be monitored to safe-guard infants from any possible change in lifestyle by mothers. --- Ethics and consent to participate HBPP participants were included in all discussion of the study including empowerment indicators, study design, assessment tools and distribution of study findings. Study participants signed consent forms to participate in the study; however, consent did not include personal identification of information they shared. All study participants were over the age of 16 years. Canadian Indigenous Health Research governance recommends that researchers and communities should work collaboratively for research in a community-based process. This interaction is recognized to increase acceptance of research findings by the population and the relevance of recommendations for the population's health [19]. OCAP principles further regulate research of First Nations populations in Canada, ensuring that a population has full input regarding the study, how it will be carried out and how the findings will be shared [19,20]. The study was fully approved by the Saskatchewan Health Authority Research Ethics Board. Ongoing updates regarding study decisions and progress were provided to this board. --- Procedure and instruments Expectant mothers were informed about the study at their HBPP placement and again at a prenatal health assessment carried out by the program's registered nurse at around 25-weeks gestation. Consent was reviewed with the expectant mothers at the 25 week assessment and their consent for participation in the study was received at this time. The first interview for the study was completed following participant consent for participation. Mothers were invited to the second assessment at this time, which would be carried out at two months postpartum. A 20-dollar honorarium was provided following the second assessment. A celebration event was held at the conclusion of the study to acknowledge the contribution of the program participants to the study and to receive their feedback regarding study findings. Previously established assessment tools were used to collect information regarding empowerment indicators. Tools were pretested with four program participants to obtain their feedback regarding the tools' ability to assess empowerment indicators. Their feedback recommended that opportunity be given for additional participant comments at the end of the interviews for feedback regarding participant experience with the empowerment indicators. This reporting is suggested by other researchers as a means to enhance content validity with the use of closed-ended tools for data collection [21]. Assessment of participants' demographic information, including caregiving experiences, was collected using HBPP tools in the first interview. The tools were developed and tested by Barrington Researchers to evaluate program participants in Canadian Prenatal Nutrition Programs [22]. An intake questionnaire, developed by Addiction Services in the health region, was used to assess study participants' drug and alcohol use. Both employ closed-ended questions. This assessment, however, was not a part of any program evaluation. Rosenberg's Self-Esteem Scale measured selfesteem [23]. Respondents assessed ten self-esteem statements on a four-point scale ranging from "strongly agree" to "strongly disagree" with a higher score indicating higher self-esteem. The RSES has a coefficient of 73% for reproducibility, 72% for individual's scalability and an internal consistency coefficient of .84 to .87. Fawcett's Inventory of Functional Status after Childbirth assesses caregiving behaviors characteristic of optimum caregiving function [24,25]. The IFSAC was used to collect data about caregiving activity by a study participant before and after giving birth. The tool contains five sub-scales measuring a mother's caregiving functioning: family care, self-care, household activities, social and community activities, and education/occupation. Respondents rate a total of 36 items using a fourpoint scale. Higher scores indicate better caregiving ability. Content validity measured by the researcher for this tool was established as 96%. Data was entered into an EpiInfo data base and analyzed using Version 16 of the Statistical Package for Social Sciences. Indicator measurements using instrument scores were reported. The T-test and Chi square analysis were used to evaluate sub-group differences. Correlation analysis examined the extent of the relationships between possible factors influencing a mother's decision to breastfeed. --- Results Study participation was maintained in conjunction with mothers' participation in HBPP. Of the 53 mothers who agreed to participate in the study within a six-month span of invitation, 51 or 96%, completed both assessments . The two mothers who did not finish the last interview had moved to another location and could not be contacted for the final interview. However, only the data of those completing both assessments was used for evaluation. In the study group, 40 mothers chose to initiate breastfeeding but only 32 continued to breastfeed until the two-month interview . Eleven chose not to breastfeed for infant feeding. Two mothers identified as HIV positive and were not supported to breastfeed due to the risk of transmitting HIV to their infants through the breastmilk. --- Indices of caregiving empowerment Indices of caregiving empowerment were measured and compared to the mother's chosen method of infant feeding. A change in self-esteem from pregnancy to postpartum was significantly correlated to a mother's infant feeding practice . The mean scores for mothers who continued to breastfeed at two months postpartum increased significantly from 2.87 prenatally to 3.57 postpartum . For the mothers who did not breastfeed, there was a decrease in the mean self-esteem score from 3.05 prepartum to 2.18 postpartum . The findings for mothers who did not breastfeed have limited value given the small sample size. However, other research of larger study groups established a decrease in confidence with caregiving when mothers did not breastfeed in larger study groups. These mothers were often identified to be adolescent, having limited resources or marginalized in some way [13][14][15]26]. Significant change in caregiving function was also correlated to infant feeding choices . The average caregiving function scores of mothers who did not breastfeed decreased from 2.66 prepartum to 2.26 postpartum . However, for mothers who continued to breastfeed at two months postpartum, the mean caregiving function score increased to 3.16 postpartum from 2.60 prepartum. Lastly, the most significant change observed with breastfeeding was related to drug and alcohol use. For mothers who breastfed, there was a decrease from 59% to 9% for drug and alcohol use, a dramatic difference compared to non-breastfeeding mothers, where there was no change in scores for drug and alcohol use . During the second interview, several participants identified breastfeeding as becoming a "new addiction" and admitted returning to breastfeeding after weaning, afraid of losing the sobriety they had gained with breastfeeding. --- Correlations to breastfeeding decisions Selected determinants of health, discussed in the "Toronto Charter for a Healthy Canada" [27], were measured to identify their relationship to breastfeeding outcomes. Specific determinants consisted of social support networks, support of family and friends, and formal education. The staff's experience with HBPP clients led to measurements of age, previous breastfeeding practice, and the presence of a partner as possible determinants affecting a mother's breastfeeding choice. Support from family and friends, in addition to program support, was found to be important for promoting breastfeeding . This was consistent with research findings which explored the value of this support to promote breastfeeding in disadvantaged situations [13][14][15]21]. For mothers who initiated breastfeeding, 27 out of 40 attended HBPP programming every one to two weeks. Mothers were 88% more likely to breastfeed when support from family and friends was average or above average. Among the eleven that did not breastfeed, nine rated family and friend support as average or less ; only four attended programming more often than once a month. Somewhat surprisingly, having a partner reduced the practice of breastfeeding . Of the mothers who continued to breastfeed at two months postpartum, only 19 of the 32 participants were with their partners as compared to 16 of the 19 mothers who were no longer breastfeeding. Overall, the mothers who were breastfeeding reported less contact with their partners due to partner drug and alcohol use. These women recognized that such a relationship could jeopardize their ability to continue parenting. Breastfeeding initiation was most likely to occur when mothers were able to maintain primary caregiving responsibility of the infants . Nine study participants lost their infants to government foster care following delivery. All were multiparous and lost their infants because of past drug and alcohol use; none had ever breastfed. Through the assistance of HBPP staff, four maintained the use of their own milk for infant feeding by providing expressed breast milk to the foster parent. Two of these four mothers were reunited with their infants prior to the two-month postpartum interview. Demographic information and postnatal experience provided insight for program support . Fig. 2 Means comparisons for self-esteem before and after infant-feeding outcomes Fig. 3 Means comparisons for care giving function before and after infant-feeding outcomes Younger mothers, aged 18-26 years , were more likely to initiate breastfeeding than those who were more than 26 years old, making them an especially important group to target for infant feeding information prenatally. Primiparous mothers were more likely than multiparous mothers to initiate breastfeeding; however, six of the eight mothers who discontinued breastfeeding were primiparious. This result suggests breastfeeding support in the postpartum continues to be important for this group of mothers. The majority of mothers who chose not to breastfeed were in the oldest age category, 26 years or older , with most never having breastfed before ; they were also less likely to attend HBPP programming. Further examination of this situation is needed to understand how this group of mothers can be engaged to initiate breastfeeding. --- Discussion The study underlines the importance of promoting caregiving practices, such as breastfeeding, that empower mothers' caregiving association. This is true even when issues of drugs and alcohol are faced. Not supporting them with this choice can permanently jeopardize caregiving associations, as was seen in North Central Regina. Using the punitive approach of placing children in government care to promote caregiving association has only led to on-going issues of substance use, violence and loss of caregiving roles in the population. This research has found that reestablishing cultural identity with caregiving through breastfeeding has proven to be a more effective way to promote mothers' caregiving association. While diligence was asserted to promote the strongest evaluation possible with this population and their infant feeding, conclusions are limited to the mothers of this group. However, attention to the need for cultural perspectives in health promotion is identified in other reseach [27]. This type of promotion has led to members of the population experiencing an increased sense of self due to the realization that the strength of their beliefs can promote health and function [28][29][30]. Research guided by a community-based research approach is recognized to increase the population's perspective regarding health practices and to better inform healthcare workers for their support of these practices [31]. For HBPP participants who chose to breastfeed, it was observed that their commitment to breastfeeding rights increased. This is consistent with Kabeer's [16] recognition of an empowerment process with caregiving when achievements occur. Other research has linked the prohibition of showing emotions, particularly in the First Nation's culture, to increased grief reactions, which is suggested to be a part of the healing process [32]. Several study participants challenged hospital, school and mall managers when their breastfeeding was not supported in these locations. In one situation, a meeting with the provincial government was set up following an insult experienced by one mother reprimanded for breastfeeding in the mall. This resulted in a breastfeeding-friendly statement coming from the ministry. These interactions further enhanced attachment to breastfeeding and recognition of its value for the infant and their own caregiving association. It is wondered if the pursuit by some participants later on of careers including nursing, addiction support work and paramedics could be linked to a positive breastfeeding experience. Long-term benefits observed with breastfeeding for maternal health are relevant for this population given their Fig. 4 Percentage comparisons for drug and alcohol use before and after and infant-feeding outcomes health risks for diabetes and cancers. In a prospective Danish cohort study, an inverse association was observed for breastfeeding duration and weight retention up to 18 months correlating with anthropometric measures seven years after delivery [33]. For mothers who already have symptoms of gestational diabetes mellitus, breastfeeding has a protective effect against the development of type-2 diabetes [33]. In a large systematic review including more than 9000 abstracts and 29 systematic reviews and covering 400 individual studies, the effect of breastfeeding for long-term health of mothers and infants was investigated [34]. A history of breastfeeding was associated with reduced risks for type-2 diabetes, breast and ovarian cancer. Early cessation, or not breastfeeding at all, was associated with a higher risk of postpartum depression. Attention has also come to the omission of breastmilk for use with infant feeding in the consideration of gross domestic product. In Norway, it is estimated that the market value of breastmilk, lost to formula and baby food sales totals $70 billion [35]. It is also estimated that health care costs incurred for premature deaths in United States, associated with low breastfeeding, is $4.38-24.68 billion [36]. Similarly, morbidity costs for diseases directly related to low breastfeeding are $733.77; indirect costs of disease are estimated to be another $126.1 million [36]. Likewise, in the United Kingdom, the costs for healthcare during 2009-2010 to treat illnesses associated with suboptimal breastfeeding was 957 million pounds for mothers and 89 million pounds for children [37]. Infant benefits directly from breastfeeding are linked to protection from infections and biological signals for promoting cellular growth and differentiation [38]. For example, living in crowded housing puts children at risk for respiratory infections in disadvantaged housing situations. Breastfeeding reduces the severity of respiratory problems particularly in the first 27 weeks of life. Recognizing this benefit, the American College of Obstetrics and Gynecology recommends breastfeeding infants exclusively until six months, followed by continued breastfeeding with complementary foods for one year or longer [38]. --- Conclusion The loss of traditional roles and functions as a result of colonization has contributed to issues of violence, abuse and dysfunction within many First Nations families. Children raised outside of their biological homes have been deprived of cultural knowledge relevant for roles and functions, as well as the sense of self with these. Support to re-establish this identity through experiences such as caregiving is needed for confidence with these functions. Given the importance of breastfeeding for both the mother and baby's physical and emotional health, American College of Obstetrics and Gynecology asks for a multidisciplinary approach involving practitioners, family members and child care providers to support breastfeeding in disadvantaged situations. Breastfeeding is recognized as a low-cost intervention which prevents cardiovascular disease, obesity and diabetes in high-risk women along with respiratory illness for the infant [39]. Initiatives like the BFI have an important role to play in assisting healthcare providers with reflection and reconsideration of their stance on relevant health issues. This could lead to more openminded recommendations and approaches toward disadvantaged population members receiving their care. The contribution of breastfeeding toward empowering a positive self-perception for mothers in the First Nations population cannot be undervalued. Breastfeeding is a powerful mechanism to enhance caregiving identity for all mothers. Additional research on the empowerment effect of breastfeeding in other populations is still needed to further support breastfeeding empowerment. The collection of breastfeeding experiences by traditional knowledge keepers is underway in the Regina population to further support identity with breastfeeding. Increased opportunities for mothers to breastfeed, along with collection of cultural knowledge for breastfeeding beliefs, offers a return to pride in caregiving identity and a sense of self once experienced by this population with caregiving. --- --- Abbreviations BFI: Baby-Friendly Initiative; HBPP: Healthiest Babies Possible Program; HIV: human immunodeficiency virus; IDU: injection drug use; IFSAC: Fawcett's Inventory of Functional Status after Childbirth; OCAP: Ownership, Control, Access and Possession principles; RSES: Rosenberg's Self-Esteem Scale --- Funding sources Canada Prenatal Nutrition Program, Public Health Agency of Canada. These funds were used as seed money to initiate the project. Money was used to fund research time and conference attendance by the primary author. As well, the money was used for honorariums and tobacco exchanges for community support and meeting regarding the proposed research project. Funds were also used for a ceremony held to recognize the project at the start of the research. Hospitals of Regina Foundation. This money provided funds to purchase honorariums and gifts for participants. It also covered costs for a celebration that was held at the completion of the study. --- --- Consent for publication Not applicable. Competing interests Not applicable. ---

Background: An inner-city neighbourhood of Regina, Saskatchewan continues to have recurring issues of drug and alcohol use affecting parents' caregiving opportunity. In relation to this, many children, mostly of First Nations descent, are raised in out-of-home care away from their families. With the promotion of breastfeeding, in a neighbourhood prenatal/postnatal support program, breastfeeding rates have doubled and mothers' participation in their children's care has increased. Recognition and promotion of cultural beliefs about breastfeeding is integral to raise community awareness of the practice. To bring additional support for breastfeeding, the empowerment effects observed were measured. Methods: Using a longitudinal study design, indicators of empowerment were assessed prenatally and again at two months postpartum. Indicators included self-esteem, caregiving activities, and drug and alcohol use. Outcomes of assessments were correlated to infant feeding practices and findings compared. Results: Findings supported a statistically significant improvement for empowerment scores when mothers breastfed. Mean scores for self-esteem increased from 2.87 to 3.57 (r = .90, p = <.001); for caregiving, scores increased from 2.60 to 3.16 (r = .91, p = <.001); and for drug and alcohol use, scores decreased from 59 to 9% (p = <.001).The study brings attention to the value of breastfeeding for caregiving in situations of addiction and limited resources. Practitioner reflexivity in regards to their support for breastfeeding is critical and includes openness to alternate breastfeeding situations and beliefs. The study found that a positive outlook on breastfeeding is the first step for a practitioner-client relationship that fosters confidence for marginalized populations.

Infotainment and the current Spanish audiovisual context Infotainment is the tendency to address news information in the form of entertainment or show business. Starting from the premise that being interested in entertainment involves "a cultural process that is not limited to the media, but is observed in different aspects of contemporary society" , it is understood that the very idea of "culture" becomes confusing and multifaceted, making "space for much of human activity", as it is approached from "a multitude of points of view and disciplines" . García Avilés reasons that "content and narrative forms are selected taking as the principal criterion the impact they can have on the audience, rather than their ability to provide relevant information in the most rigorous way possible", hence, for example, YouTube transforming into a catch-all, ranging from videos known as "tutorials," where "formal and informal educational knowledge" is shown , to other audiovisual proposals of an analytical or opinionated nature in which "very active creators such as youtubers have become opinion leaders and massive phenomena" . It is worth asking whether this is due to the fact that they are more accessible than other traditional media figures, as it is possible to have a "new conversation" with them that is "subjective and free, insofar as conversations begin and end, are resumed or abandoned without protocol" , which implies a new consumption that is dependent on "the circulation of everyday and expert knowledge, how it is appropriated or not, and, of course, to whom it implies a border, and thereby exclusion" or integration. Twitch also represents another major competitor to traditional television, with some studies showing that Spanish consumers "believe that Twitch has the potential to equal television as a favorite audiovisual entertainment medium and even surpass it to become the first choice for entertainment in the long term" , although live streamers, in principle, do not seem to differ so much from those of television, except that time limits disappear and that "content creators are aware that most people who follow their broadcasts have them as background while doing other things", in a so-called radio mode, that is, "something that allows the same channel to be used as television or radio depending on the attention paid by the user" . In terms of new trends or audiovisual formulas, for some authors it does not seem so necessary to name or classify programs, spaces, or sections, instead prioritizing the final feeling that remains after viewing them; or, in other words, to assess whether a viewer has been informed and/or had fun watching them, and which of the two feelings predominates, understanding that "the hybrid phenomenon is also related to a change in the audience's reception of the messages broadcast by television media" . Likewise, "interesting, fresh, and original content" is necessary "since the public, generally synchronous, seeks surprise from a clear concept that corresponds to a pioneering idea" , and another point in favor that is gaining more and more followers is the option of participation, either through Twitter, in the case of traditional television, or chat, donations, and subscriptions, in the case of YouTube and even more so Twitch, since "it offers a direct opportunity to interact, talk, and create a community around the figures of content creators", despite the fact that "the very development of the platform suggests concomitance with the old formula of success of television communication: the live audience, sharing the same content synchronously" . Regarding television, one should not forget the changes produced since its first stage in Spain, when the channels offered were expanded in 1990, which ended TVE's monopoly and marked "the passage from captive to shared audiences" , or when digital terrestrial television was implemented in 2010, establishing the duopoly of Mediaset España and Atresmedia, which together retain 58.4% of the audience. In the case of Atresmedia, hybrid proposals ended up being established when it came to planning the programs, with an infotainment more linked to humor and politainment predominating, so as to continuously resort to political information, since "Atresmedia's strategy consists of dumping all the programs with political content on its second channel, La Sexta" , which is the case of El intermedio , broadcast since its establishment. Similarly, other formulas such as Espejo público , in its morning magazine format, alternates news topics with formulas that appeal to the audience. Additional, more recent examples can be seen, such as Todo es mentira , which is another prominent case of an infohumor program that analyzes fake news broadcast by television or other media, relying on resources such as social networks to interact with potential audiences and even to incite debate. Furthermore, there are also media figures who, in addition to hosting their own programs -hybrids between journalism and show business-participate as collaborators in entertainment programs, such as Cristina Pardo, cohost of Más vale tarde and Thursday night talk show host of El hormiguero , not to mention the fact that these programs increasingly resort to occasional contributions from specialized analysts who are mainly found on YouTube, such as Juan Ramón Rallo or Rocío Vidal, La Gata de Schrödinger. --- Transmedia consumption and the new challenges facing infotainment professionals Because television has been "the main cultural mode we have to know ourselves" , and the fact that the Internet and social networks are increasingly present, such presence in turn must be increasingly perceived on television, especially in infotainment, which "constantly pursues the approval of the public" , causing hybrid trends to become inseparable from the concept of social television . This stems from the practice of question-asking, which "generates an extension of the main content on other platforms and establishes some cross-media productive routines with the purpose of generating a permanent dialog with the audience on second screens to achieve a greater engagement with the broadcasted content and their protagonists" . When engagement is delved into in a deeper way, "the audience is no longer understood as a passive entity, which is placed at the end of the content distribution process and whose only value is to be reflected in the industry's information systems" , hence traditional television networks increasingly emphasize "transmediation" strategies that retain younger audiences and allow them the option of consuming their content for free through other channels. Thus, some argue that audiences are migrating to new, on-demand television services, independent of live broadcasting, and others consider that we are witnessing the "decline of the medium owing to the new possibilities of delayed consumption, although they recognize that it is still early to guarantee a change in trend because there are still no data available on the convergence of audiences in the media" . Regarding political information, Twitter has been positioned as the main network for communicative exchange thus far "for its ease of use, for allowing real-time commentary regarding what is viewed, and encouraging interaction with other users, with the program itself, and its protagonists" . However, users have become increasingly accustomed to the use of social networks "to comment on what is happening in their daily lives and to share their television experience: 85% of active Twitter users talk about television in prime time" , finding in digital platforms a new, more dynamic television, with charismatic figures such as Ibai Llanos, who "is currently the owner of the Spanish-speaking channel with the largest audience on Twitch and the fourth worldwide" , and which has generated enough media impact for journalist Jordi Évole to interview him on his program Lo de Évole on March 7, 2021. However, although a "change of control" is discernible in terms of ceding some prominence from the professionals to the viewers, this does not mean that the latter take advantage of all the "technological opportunities to personalize television viewing" , owing to the fact that, in most cases, they consume fiction and entertainment, so "some viewers intersperse their Internet conversation with comments about their daily routines and personal circumstances, and use Twitter to recommend entertainment to other users" . Thus, the audiovisual trend has evolved from a primitive television, imitating cinema or old journalism, to a more reciprocal and inspiring one, as "streaming, social networks and digital media in general provide spaces that traditional media have systematically denied to ordinary people" . To this is added the idea of simultaneity, in terms of the habit of being able to enjoy several forms of content at the same time thanks to the availability of different devices, which is known as multiscreen consumption: "the action of reading, commenting on, and sharing information about television content on second screens from secondary consumption devices" , thus "there are thousands of examples of audiovisual consumption that are not being recorded and are being lost" , which Teso-Alonso and Piñuel-Raigada qualify by noting that, "while the screen that used to occupy the central stage of the home, called the 'desktop', is increasingly larger and has a more panoramic and spectacular format, others are becoming increasingly lighter and more transportable" . Media, as well as content options, are multiplying, so it is not surprising that competition is increasing between spaces and professionals in the same way. --- Objectives and methodology This research proposes to deepen the understanding of what is currently viewed and consumed on hybrid audiovisual products in Spain in terms of information and distraction, understanding that infotainment can be broadcast both through the traditional means of the television set as well as through digital channels. The idea was thus to approach programs, sections, or spaces that dealt with news issues with resources associated with entertainment and comedy. The object of study, however, was not to analyze these types of program, since there are already numerous works dedicated to content analysis, but rather the professionals involved in them, since many of them belong to one of the branches of infotainment, whether journalism or entertainment, and might be forced to adapt to the needs of other spaces in which they participate, or to the needs of the receiving public. The main hypothesis holds that the figures most valued by viewers are those who are most adaptable to the topics covered and the context in which they are addressed, regardless of whether such communicators belong to journalism or comedy, which in reality would imply being suitable for both in the eyes of viewers. As a complementary hypothesis from the audience's point of view, audiences seem to appreciate the professionals who are a bit more unpredictable, as long as they do not attempt to go against the rigor of their original profession, i.e., a journalist making jokes with certain unacceptable lines, or a comedian not overreaching in their comments on the news of the day. In this sense, taking into account personalities such as Ibai Llanos, brimming with "energy and spontaneous impudence" and who continually repeats that he is not entitled to give his opinion on news issues despite conducting interviews with people involved in them, another research question is whether audiences hold figures such as Llanos in higher regard than established journalists on the Spanish audiovisual scene. The third hypothesis is related to the perspective of professionals, suggesting that they feel some unease toward personalities such as Ibai Llanos or Jordi Wild and see their interview spaces on Twitch or YouTube as an increasingly invasive emerging competition. To corroborate or disprove these reflections, a qualitative methodology composed of in-depth interviews and focus groups was applied. The interviews were conducted with communicators and/or audiovisual professionals. For the selection of profiles that compose the sample, some previous studies took into account "the circumstances in which the communicative products to be analyzed are constructed" , paying attention not only to those who appear on screen, but also to the "agents of production" Pérez-Pereiro, 2007, p. 70), while other authors take as a reference parameter the success of a space as associated with its longer broadcasting time , thus establishing its creators in the collective imagination. For this study, the interviewees were selected according to their functions, roles, and specific characteristics, with at least two people belonging to similar occupations to identify similarities or differences in the performance of their role. Therefore, it was deemed convenient to consider the profession of the presenter/host of programs, preferably involving a certain polemic relevance; so for example, Vicente Vallés and Antonio Castelo, the former a journalist and presenter of Noticias2, the evening news program of Antena3, and the latter a comedian and collaborator of Todo es mentira, an infohumor space, represented two totally different ways of approaching information. The same contrast was intended to be made in terms of the female figure, thus Cristina Pardo, co-host of Más vale tarde and collaborator of El hormiguero, and Rocío Vidal, influencer and content creator for her YouTube channel, La Gata de Schrödinger, and who has participated in various journalistic talk shows such as La sexta noche , were interviewed. The role of the program director was also considered, so José Antonio Lavado, deputy director of Todo es mentira, and Jorge Gallardo Camacho, deputy director of the morning magazine Espejo público were interviewed, although both with the purpose of dealing with newsworthy issues in a manner closer to infotainment than to classic moderate information. The six interviews were conducted by telephone or online and lasted an estimated 20 minutes, consisting of 6-8 questions regarding their professional dynamics, their impressions of other media figures, or their impact on Spanish audiences. To address the contrast of opinions within the audience, three focus groups were conducted with potential consumers of television infotainment and Internet audiovisual products that were the object of the research. They were recruited through social networks such as Twitter or WhatsApp, or by resorting to the snowball method through social networks to identify participants who were interested and involved in the field of study. With the purpose of bringing to light generational factors that could influence group dynamics , one of the groups consisted exclusively of eight young people aged 20-34 years; the second of eight participants aged 41-68 years; and the last of nine people aged 21-64 years. That is, there were a total of 25 informants between the ages of 20 and 68 years, of whom 13 were women and 12 were men. The two groups differentiated by age were carried out first, then the six interviews with professionals, and finally, the group composed of participants from both generations of consumers, with whom the results obtained in the first groups and in the meetings with journalists, comedians, and content producers were compared. The scripts of the dynamics revolved around the following themes: the interest of whether to address newsworthy issues with entertainment formu- The audiovisual sector has evolved from a primitive television, imitating cinema or old journalism, to a more reciprocal and inspiring one las; whether there are professionals and/or figures who are more legitimate than others to work in infotainment; and whether the channel on which these media personalities appear is important in terms of their credibility and establishment. --- Results When reflecting on audiovisual consumption, the question that arose from the outset, both in the interviews with professionals and especially in the audience focus groups, was that of the principal way in which they viewed content, that is, whether they used traditional media or online resources. In this sense, perceptions about the boundaries between one medium or another were blurred, and in all cases, preferences depended on the content offered, the clarity and convenience of how it was presented, and whether one communicator or another was able to retain and secure their audience, regardless of which branch they originally belonged to: journalism, entertainment, or humor. "I have journalists who I like the way they tell me things. [...] And I think the new generations are looking for personalization. [...] Then, as they feel they are connected to streamers and youtubers, well, in the end that is what they attract, and that is not informative, but pure entertainment" . Despite the explanations given by the participants in the discussion groups, and their conviction that they know how to distinguish one channel from another, or one audiovisual proposal from another, the professionals interviewed argued that, for them, preferences depended first on what was provided to the user-spectator, both in terms of platform and content, and then, subsequently, a viewing criterion was generated according to the nature of the space or the type of communicator offering it: "Many people, many young people especially, are not only informed through traditional media, but they are in their free time, or when they have time, and they open YouTube, for example, and say 'oops, this person has talked about this topic so let's see what they think' and from there draw their own conclusions, and also have a good time. So, I think that balance between entertainment and information generates an engagement that makes people want to continue watching your videos because; apart from the classic information, it is also a video that can be entertaining for them" . "I really like my work in Todo es mentira because I think it is the purest function of the comedian that there is; it is also a bit similar to what I do in A vivir que son dos días, because all the time I am playing against reality; to go against it is the natural function of the comedian, and it is summarized in the question I ask all the politicians when they come on the program as guests: 'Have you ever been forced to tell the truth?' It is engaging in current affairs from a critical-philosophical point of view" . "Both Susana Griso, as well as Espejo público as a whole, is an opinion leader, because she is a person who is not limited to being a talking head because of the identity that presenting a program like that gives her; then, precisely in that part of -tainment, of infotainment, that is where a presenter is allowed to be human, to have personal assessments, and to empathize a little more with the viewer" . This question as to whether audiovisual professionals can continually move from information to analysis, opinion, and commentary, or to humorous nuances gave rise to continuous debate among those consulted. The professionals interviewed seemed to approach this issue with greater permissibility than the audience focus groups, as they considered that the same barriers between programs, and even between media and channels, are disappearing, and that presenting or collaborating in an informative program had nothing to do with participating in an entertainment space via traditional television or Internet platforms: "When someone goes in front of the TV, what you're looking for is for them to be the best communicator they can be. They may or may not be a journalist; they may or may not agree. A journalist is something else, or may be the same, it may happen that there are different communicators who are journalists and perform this double function, but they communicate the journalistic product that is produced by a newsroom with people who specialize in that product" . Preferences depended on the content offered, the clarity and convenience of how it was presented, and whether one communicator or another was able to retain and secure their audience "I have always believed in the possibility of sharing current affairs in a lighthearted way, without losing credibility. I believe in rigor, but not in rigor mortis. And El hormiguero is not La isla de las tentaciones, where it would perhaps be more complex to defend a purely journalistic approach. You don't have to have so many complexes" . "Making a program that is not entertainment, purely informative, does not imply that you can't also go to an entertainment program at a certain time and deal with the topics you may be a specialist in in a more lighthearted way. This is not something that we have invented in Spain, the programs of British, French or American television, there are many entertainment programs that also deal with informative matters, let's say, in quotation marks, serious, in a more casual way" . The participants of the audience focus groups did not entirely agree with this view of the professionals, and respected one or the other more or less depending on whether they did not overstep their predominant functions. In other words, they could understand an occasional appearance on entertainment and variety shows, or in interviews and talk shows on YouTube or Twitch, but this second part had to be very complementary and anecdotal so as not to consider that the professional was straying too far from their competencies. They could give them credit as long as the comic-political role of the media character was well defined and well delineated, as far as the format in which they appeared allowed this: "I don't watch youtubers. And, what's more, I don't even like that kind of hybrid program, because there are many programs of that type on TV. What do I know, [David] Broncano has been on Movistar+ since the beginning, and his programs are still being broadcasted and such. I don't find them interesting, because, man, sometimes I've seen a little bit and they don't entertain me, nor do I think that what they inform me about is very interesting" . "I think that, for example, the character of Risto [Mejide] is useful above all to generate controversy and use controversy to get a lot of information, right? Because when he is polarizing, he forces people to place themselves in one extreme or another, and that is something that I really like about the character he plays, that it can be considered favorable if you want to learn something new" . Considering whether audiovisual communicators are overreaching is precisely what led to the concern about the politicization of the spaces, an issue that, in principle, most participants disliked. Furthermore, they only considered it to be legitimate when the professional communicates in advance what they think and takes a personal position, but never in a masked or subversive way while presenting or analyzing news content: "I believe that the greatest achievement they have obtained here in our country is Atresmedia. Atresmedia has managed to make a coin with two sides: one is Antena3, the other is La Sexta, and each of the channels gives the bait to those political followers they have, with Antena3 giving a more right-wing version, and La Sexta in theory being the left-wing one" . "It's just that that is the issue. Do we know how to distinguish opinion from news? Maybe not. But, when I realize, when I say 'this is an opinion', it makes me very angry. [...] When I realize that, it makes me very angry and I clench my fists, because it's as if you've slipped me your opinion and I've realized it, I've seen it" . Regarding the position of the professionals interviewed, they stated that they deeply respected their consumers, viewers, and followers, insofar as their intention was to offer them a consistent audiovisual product, tailored to the format, the channel, or broadcasting impact, since they understood that each space marked its rhythms and languages, which did not necessarily have to be shared by everyone who watched them, so their discourse could be modulated according to the lesser or greater diversity of audiences: "In this program we play a lot, we laugh a lot, and we create a lot of humor, but we take it tremendously seriously, and every time we make a decision, each and every one, it is based on deeply respecting that the viewer is a person at least as intelligent as we are" . "I appeal to the critical intelligence of my viewers. When I use a sarcastic tone or when I make a joke about something, it's like spoken 'sublanguage', and it's like when you're talking to your friend, isn't it? [...] The TV tone is totally different. The codes used in social networks, the memes, the ability to edit your own videos, for example, to make a joke at a given moment; television does not allow you to do that because you are in a foreign medium" . As more and more content creators, analysts, and even journalists are positioning themselves on social networks or creating their own YouTube or Twitch channels, regardless of whether they are involved in traditional media, it is often this fame that gives them the opportunity to once again be claimed by television to participate in different spaces; meanwhile, some youtubers and streamers have news talk shows or carry out interviews without necessarily being journalists. The professionals and audience focus groups discussed whether content creators were invading the sphere of press or television professionals to the point of becoming confused or overlapping with journalists, with the participants consulted recognizing that this issue creates a generational division of positions and of understanding in their environments: "There are a lot of well-known youtuber-type journalists. Carles Tamayo is a journalist, but this guy that I see more often because of my children, Jordi Wild, for many younger people are journalists. In other words, my son identifies these youtubers as journalists. Maybe for my mother it is Vicente Vallés or the people who appear on TV, but for my son, it is Jordi Wild or Tamayo. I have witnessed real pitched battles at home between my mother and my son, because for my mother Carlos Herrera is God. Then my mother explained to him what a journalist is, and my son said 'no, Tamayo has been involved in I don't know what, and he's been caught with I don't know who', and my mother said 'he is the greatest thing in journalism', and the two of them discussed who is a journalist and who is not" . As a specific research question, professionals and participants were asked whether streamers such as Ibai Llanos were direct competition for television professionals. The former said they did not see them as their rivals, as they believed deeply in the freedom for anyone to offer content and proposals through any channel, while the latter felt that professionals, in any case, had to deal with it, because times change, they said, and those who do not adapt end up being cast aside in favor of more attractive alternatives: "What Ibai does is take advantage of the opportunity he has to interview people who are in the news, who would also be of interest to journalists. You can be a great communicator without having to answer or comply with all the requirements demanded of a journalist" . "I have a lot of respect for the work of any content generator, and of course the streamers have a very notable success with the public, and I think that is very praiseworthy. I think they do a specific job for a certain type of viewer or listener, and they enjoy unquestionable success" . "If many people follow them, it must be because they are interesting, and maybe that's what conventional TV should have done; I don't know, they've been introduced on the side and are making a niche for themselves; I think it's good. I think the point is more for people to consume and understand that Jordi Wild, for example, is a youtuber who does entertainment interviews, with his opinion and so on, which is not the NO-DO [A Spanish newsreel from the past]" . Thus, in the various conversations in the audience focus groups, audiovisual proposals emerged that were much more attractive to them than traditional television, which is why they said that some programs have been using social networks or platforms as a method of engagement for some time, such as Todo es mentira or La resistencia: "If I put something on to watch on TV, on some channel, it's I don't know, something like El intermedio or Jordi Évole's interviews, which I like a lot, or Ana Pastor's interviews. But it's not the norm, it's rather unusual, and I don't know, if I'm eating alone, or I have some free time and I start, it's more like I'm going for a fixed shot, maybe 'well, on YouTube I'm interested in such and such, I like this podcast that I know they comment on more current affairs', and I go and listen to it" . "I started watching La resistencia on YouTube, and for the last year I've been with Movistar+, and on there I watch the whole program every day. Not when it is broadcast, but when I have breakfast, or when I take advantage of meals, es- The professionals interviewed considered that the same barriers between programs, and even between media and channels, are disappearing pecially when I eat, that is when I watch it. And more than the interview itself, to see him [David Broncano], to see the comedians in general" . In the specific case of younger audiences, when they consider watching audiovisual content, whether it was television or not, they agreed that they were more likely to look for specific videos on YouTube, in the case of women, and on Twitch, in the case of men, even though the participants in question were not regular consumers of these platforms. No one disputed that some of the well-known personalities appearing on these audiovisual channels have a following that exceeds the expectations and predictions of many television networks: "I consume YouTube, for example, such as microprograms, a channel that talks about certain topics, uploaded in a fifteen-minute format, always about a topic I like, weekly, which is a less rigid format that maybe TV could not afford. And Twitch is a little bit the same; first, it is a medium where listening is active, plus they bring something, an Ibai, an amazing thing where people write, it goes so fast that you will not even read yourself, nor will you read anything, nor will they read what you write, you know perfectly well. But it's a kind of active listening. You're kind of actively out there doing things" . "Are influencers killing TV stars? No. It's just a new approach to the origin of the star system. Before, the star system was monopolized by the cinema, only movie stars were recognized by the whole world, then television began, and to this was added the star system of radio stars, so little by little the origin of what stars are was diversified, and what has happened is simply that a new star-creating agent has appeared, audiovisual in this case, and they have escaped from the powers of the big media. So, are they competitors? No, I believe that in the end it is a situation of coexistence. It can even be said that the selection of who is a star has been democratized, although under the same criteria as television" . In fact, another interesting question that arose regarding this supposed alternative star system or media figures who can jump from television to platforms and the Internet indiscriminately was that the viewers consulted did not distinguish between interviews and talks on YouTube or Twitch channels and those done via podcasts, insofar as the latter are consumed in the same audiovisual way, or because they are simply presented as such: "My wife usually watches these programs, half entertainment, that help her to clear her head, to disconnect a little from work, and I usually use the tablet or my phone, mostly, also the Internet and YouTube, and podcasts. Also, podcasts are very convenient because you can listen to them anywhere, you don't have to be watching a screen" . "Many times, I may see that a certain interview of a certain person is a trending topic, but I'm too lazy to look for it, turn on the TV, and search for the channel. I'll wait for the video and when the video is available I'll watch it, because I'm sure someone will post it, even if it's just a summary on my cell phone. But bits of television, short videos, from La resistencia or an interview with Jordi Évole" . The audience focus groups consulted thus did not differentiate channel or platform as much as they claimed, because the format and type of exposure seemed similar to them. The only feature they highlighted to justify their impression of consuming a different product, either to categorize it as more conventional television or more typical of YouTube and Twitch, regardless of whether it was offered by a journalist or another type of communicator, was the time: the feeling that the interview or the talk show is long and has the possibility for the guest to elaborate, something that did not happen, nor did they think it could happen, on television. Likewise, the participants equated this to freedom of demand, i.e., freedom of choice: the ability to choose when, where, and to whom, since on television, no matter how many options there are, there would never be as many as on the Internet, in their opinion. Audiences felt that professionals, in any case, had to deal with streamers, because times change, and those who do not adapt end up being cast aside Some of the well-known personalities appearing on these audiovisual channels have a following that exceeds the expectations and predictions of many television networks --- Discussion and conclusions After analyzing the results obtained in the interviews with the professionals and in the audience focus groups, it was confirmed that the use of social networks by programs as an online tool was becoming obsolete for viewers, in the opinion of both young and mature participants, because for them, channels such as YouTube and Twitch better met their interaction needs. If they used the networks, they did so mostly "to obtain additional content or learn more about the collaborators, and not so much with the intention of interacting with them" , in line with similar studies that show that paid humor formats prefer to offer "small doses from transmedia narratives, through Instagram, as an engagement strategy that allows for reaching the general public" . On the contrary, some of the professionals of programs consulted, such as Espejo público and Todo es mentira, did state that they continue to use social networks, especially Twitter, to involve their audiences in the program, or to promote debates, although none of the participants in the focus groups acknowledged having used this system, although they had used, or knew people who had used, YouTube or Twitch. Thus, when it comes to interpreting which figures are the most valued by the viewers consulted, those belonging to the YouTube, Twitch, or podcast sphere enjoyed a higher regard than those linked to traditional media, reflections in line with previous works that declare Ibai Llanos as the unbeatable leader of Spanish-speaking audiovisual content . This was the case even for older audiences, because many of them acknowledged following media figures who came from television or the traditional press only because they had moved to online broadcasting, with greater freedom to express themselves and present their content in their own way, confirming that the "pain threshold of comedy," that is, of the concessions or license allowed to the figures and the spaces, depend on the type of format, scheduling -in this case nonexistent-and the degree of broadcasting . In this sense, the main hypothesis, viz. that viewers value those figures who are more adaptable to the topics dealt with and the context in which they are addressed, regardless of whether these communicators belong to journalism or comedy, is confirmed, because what concerned them above all else was that they worked consistently and that the content offered was interesting, with more merit if they were glued for several hours to a screen, something they would not do with television, because its rhythms and restrictions were more rigid. As a complementary hypothesis, regarding the viewers' perspective, the audience focus groups appreciated the professionals who are unpredictable as long as they did not violate the rigor of their original profession, i.e., a journalist could make jokes within certain limits, or a comedian could stay within the limits of their supposed analysis of news information. In this way, personalities such as Ibai Llanos or Jordi Wild were respected, because in the opinion of the participants, they always reflected on topics from their position as mere generators of entertainment, and for this reason they received greater esteem from the focus groups insofar as the latter recognized that some established journalists of the Spanish television scene did go beyond their competencies, often in a subversive and unclear manner. However, the third hypothesis, which held that television professionals would feel uneasy toward online content creators and would see them as competitors and invaders, was refuted, since the interviewees did not feel threatened by figures such as Ibai Llanos, and considered his interviews to be very different from the journalistic style of the one they practiced. It was therefore seen that any professional can move through different hybrid programs and play roles assigned to any genre or media proposal as long as they have the capacity to perform such work, thus constituting a sort of "hypermedia star system" that, in imitation of the Golden Age of Hollywood cinema in the early twentieth century, puts forward presenters associated with specific personalities, behaviors, and even political ideologies in an attempt to transmit their essence to the programs and establish their success, since "they bet on a recurrent artistic casting that provokes on-screen chemistry with co-presenters that converge in the figure of the presenter" . This also demonstrates that audiences are increasingly aware of the adaptation of traditional media to the Internet, to the extent that they have clearly identified news figures in entertainment programs and comedians in news programs, many of whom are willing to make the leap to YouTube and Twitch. However, it is still too early to assess the consequences of these perceptions on the public's understanding, issues on which professionals do not tend to dwell, as Twitch is becoming a parallel television, unpredictable in its evolution in a society that still "does not know exactly what a platform of such magnitude means" . Studies such as this one are just a first step toward delving deeper into these emerging Internet figures, often very close to infotainment in both form and content, but who lay the foundations for a new way of understanding audiovisual consumption, and which will require more research as to the reception and audiences, who are connected to the concept of transmedia consumption at all times. Any professional can move through different hybrid programs and play roles assigned to any genre or media proposal as long as they have the capacity to perform such work, thus constituting a sort of "hipermedia star system" Viewers value those figures who are more adaptable to the topics dealt with and the context in which they are addressed, regardless of whether these communicators belong to journalism or comedy --- Este artículo se puede leer en español en: https://revista.profesionaldelainformacion.com/index.php/EPI/article/view/87410

Spanish television is increasingly subject to transmedia consumption. Faced with traditional models in which journalists limited themselves to rigorously transmitting information to strengthen their audiences, the networks' commitment to infotainment, as well as the competition with platforms or with figures from YouTube and Twitch, forces professionals to reinvent themselves, often by resorting to entertainment and show business resources. TV programs such as El intermedio (La Sexta, 2006) and El hormiguero (Antena3, 2006) have been working for years to bring journalists and comedians together in the same space, and others such as Todo es mentira (Cuatro, 2019) interact with audiences through social networks such as Twitter and Instagram. The question is whether these efforts are sufficient or whether we are witnessing a transition period in which interviews conducted by content creators such as Ibai Llanos or Jordi Wild will end up being more highly valued than those of a journalist. To answer these questions, six professionals from the current audiovisual scene were interviewed:

Introduction Flickering across ephemeral screens, digital stories appear to relinquish their status as cultural heritage 'objects' that sustain and empower via their longevity and stability, especially for young adults. Digital storytelling, instead, prioritizes real-time connections and story creation, contextual adaptability, multi-media expression, and accessibility. With a smartphone and Internet access, even young creators, with a bit of practice, can instantly post a story, create or remix a video, or capture and narrate an event in real time. Thanks to GPS-location technologies and mobile cellular phones, storytelling can happen nearly anywhere, which brings storytelling into proximity with lived experience in newly intimate, entangled ways. How might we, as educators, draw on the dynamic, multimodal affordances of digital storytelling as a way to engage high school students and enable them to recreate personally and culturally meaningful connections, building a story-based sustenance for the twenty-first century out of what might seem to be its ruins? How might we draw on teens' digital lives to expand their fluency with creative story practices in multiple genres, enabling them to build sustaining connections with other local teen storytellers while counteracting their sense that nobody's listening to them? How might the multimodality of digital storytelling speak to and catalyze more diverse creative expression, writing, cultural contexts, and cognitive styles-counteracting a white Euro-American, colonialist fetishization of abstract, transcendent writing ? In early 2021, in the thick of COVID-19 pandemic lockdowns and restrictions, as faculty members directing and affiliated with the Center for Engaged Storycraft at the Rochester Institute of Technology , we recognized digital storytelling-and the shift of storytelling to networked and real spaces where even new creators can create multimedia digital stories-as a profound opportunity to engage high school women through storytelling. Research since then has thoroughly documented the overwhelming impact the pandemic has had on youth and on teenage women in particular , though it is early days for a definitive assessment of the complex forces-both pre-and post-pandemic-that are negatively affecting so many teen women. In our own community of Rochester, New York, it was apparent that the sudden transition to virtual learning platforms during the height of the pandemic resulted in the loss of social and emotional support outside of teens' immediate family members. We thus turned to multimodal storytelling as a way to facilitate engagement among high schoolers with their peers and to identify common ground from which they could share experiences, however diverse. Responding to a call from the Cornelia T. Bailey Foundation's New ERA Women Writers Grant, we developed and, with their funding, launched the first "Gathering Stories: A Digital Storytelling Workshop Experience for Young Women" in July 2021 on the RIT campus. We focused on high school women with an interest in storytelling and invited them to apply to participate in the week-long workshop. Our goal was to offer training in digital storytelling of diverse kinds and to facilitate a gathering of youth identifying as women-including transgender, nonbinary, and cisgender women-over the course of a week. The workshop provided the physical and interpersonal space, time, and resources for participants to explore, articulate, and connect their voices and emotional experience to a community of local women-including peers and elders-so that they would feel recognized and valued as storytellers and each could learn how to prioritize their own experience and voice as a leading, transformative driver in their educational, personal, and professional lives. In this paper, we discuss our approach to developing this digital storytelling workshop for young women, describe positive outcomes, highlight challenges we experienced in creating an equitable and collaborative storytelling environment, and finally, detail our plans for future iterations of the program. --- Theoretical Framework Much contemporary interest in storytelling and the approaches to storytelling that inform our workshop emerge out of late twentieth-century narrative studies by French structuralist linguists, literary scholars, and philosophers such as Roland Barthes and Jean-François Lyotard, who turned attention to the narratives that inform everyday life in addition to the more artful, crafted narratives we have long celebrated as literature, folktales, or myth . Barthes's influential 1966 "Introduction to the Structural Analysis of Narratives" recast narrative and, particularly, narrative in its everyday practice to include narrative discourses we carry out with ourselves and the world around us . Formal or informal, artful or bland, narrative, from this vantage point, can unfold through "an almost infinite diversity of forms"; narratives are "able to be carried by articulated language, spoken or written, fixed or moving images, gestures, and the ordered mixture of all these substances." Narrative, in other words, is multimodal, drawing on more than one semiotic and sensory channel. As Barthes initiates a new discipline of narratology that makes us all knowing storytellers, he also expands the realm of narrative to include diverse media, genres, and creators and identifies narrative "in every age, in every place, in every society"; famously stating that narrative is "simply there, like life itself" . In this vein, our workshop aims to empower the individual storyteller within each high school participant. The primary emphasis in the storytelling practice and final project is to empower each young woman to reflect on their personal experience, experiment with narrative media and methods to express themselves, and communicate something meaningful to an audience of peers. The value is largely in the interpersonal process of writing about oneself, experimenting with diverse narrative forms to compellingly craft and shape one's story, and personally sharing it with a group of peer and elder storytellers-not to create a great work of literature, though this is often a longer-term goal for many of these young storytellers. As its title, "Gathering Stories," suggests, our workshop identifies and prioritizes storytelling and listening as a central means of connecting with others through shared experience, a means of personally and collectively gathering together the pieces of our existence for shared enjoyment and reflective benefit. Barthes's and other narratologists' attention to the universality of narrative and their recognition of its centrality to human cognition, unfolding "like life itself" in our minds, led literary scholars such as Peter Brooks to explore how closely our sense of self is "bound up with the stories we tell about our own lives and the world in which we live" . "Narrative capability shows up in infants some time in their third or fourth year, when they start putting verbs together with nouns... a conjunction that has led some to propose that memory itself is dependent on the capacity for narrative" . Interest in narrative as a primary means through which we try to understand the world and construct its meanings quickly spread to psychology and then to other fields including medicine and economics, a movement since described as a "narrative turn" in the social sciences, instigated by Jerome Bruner's study of child development through the lens of children's informal storytelling among themselves and with adults in "The Narrative Construction of Reality" . Joseph Campbell similarly identifies an oft-repeated narrative structure-the "hero's journey"-across cultures and time, noting its direct parallels to stages of personal development and maturation, providing a wellknown example of research on narrative's dynamic influence on personal development . More recent interdisciplinary story work emerging from this "narrative turn" remains attentive to storytelling as a way people actively conceptualize their life experiences; it recognizes the centrality of personal narratives to identity formation and, therefore, often mobilizes story as a key to behavior change, both individual and societal for a recent model for implementing and assessing the influence of narrative in behavioral medicine). As cognitive narratologists suggest, storytelling is often enactive-i.e., stories serve as intersubjective thinking/acting tools that connect tellers and listeners and, in doing so, provide models and potential trajectories of action, connecting past, present, and future states . Inviting high school women to participate in the workshop and reflect on their own stories in the year preceding their transition from high school to college or professional life, we are attuned to narrative as a "principal way in which our species organizes its understanding of time" and, therefore, as an especially useful way for these young women to explore and build narrative bridges between their own past, present, and future, the three-part structure of a narrative's dramatic arc-its beginning, middle, and end, as first identified by Aristotle. We underscore the emotional shape of a narrative's rising and falling story arc as it moves through time and space like a smooth arc or a more dramatic, winding rollercoaster, encouraging these young women to envision the dramatic, emotional "shape of their story" of their, at once, personal and narrative transformation. Our workshop participants are given complete freedom in their choice of a story to tell, as long as it draws from their experiences, and yet over ninety percent of the final stories, regardless of their diverse media, feature a pivotal moment of personal realization or maturation, or prepare for it by reflecting on a childhood past, a present, and an as-yet-unknown near-future. While this illustrates a familiarity with personal storytelling conventions, the teen storytellers' emotional investment in the particular stories they choose to tell also evidences their awareness of narrative's power to meaningfully shape their experiences and, as a result, provide a reflexive means of revisioning themselves and their relationship to a broader community. Importantly, there are continuing, necessary debates about the extent to which narrative informs all people's sense of self, even if it seems neurotypical . In addition, the narrative turn and narrative constructivism that grew out of late twentieth-century narratology and social sciences have been rightly critiqued for taking the universality of narrative so far that it eclipses non-narrative modes of communication altogether or entraps us in a world that is exclusively narrative, with no access to material reality outside the text . Peter Brooks's Seduced By Story: The Use and Abuse of Narrative describes his disabused sense of what has happened to narrative in the last century, describing a harrowing "narrative takeover of reality" in the twenty-first century as stories abound: "[n]arrative seems to have become accepted as the only form of knowledge and speech that regulates human affairs" . While Brooks is correct in his assessment of how and why stories abound in such destructive ways today, particularly in political and economic domains, his call for a more nuanced and "intelligent account of what narrative is and does" is precisely the route already taken by twenty-first-century research in cognitive and in digital narratology, which continue to explore the transformative power of narrative, while providing important correctives to the narrative turn and its constructivist extremes by acknowledging the material environments, media, and events that reciprocally co-inform and co-realize narrative practices of self-understanding and of knowledge-building in given contexts or by distinct selves and storytellers. In Storytelling and the Sciences of the Mind, cognitive narratologist David Herman proposes two verbs as terms to capture the interweaving of narrative worlds and actual worlds . "Storying the world" describes the active, reciprocal processes through which we use our narrative frameworks, experience, and assumptions as a kind of extended-mind to make sense of events in our material lifeworlds . Alternatively, "worlding the story" involves processes through which we actively interpret narratives by asking empirical questions about characters and events in stories, imagining who, what or why things unfold as they do . In both instances, narrative understanding relies on an exchange between narrative storyworlds and lifeworlds rather than granting narrative full or unlimited rein over material actualities. Situating our young storytellers in the same physical workshop space daily over the course of a week and inviting local storytellers from the Rochester, New York, area, the workshop attempts to ground our storytelling practices in these specific contexts and to acknowledge the way geographical location, physical space, interpersonal dynamics, writing tools, and workshop leaders' guidance all inform our storytelling practices, as individuals and as a group. Researchers in Spain, recording human brain activity during verbal communication and storytelling sessions, recently discovered that the production/comprehension coupling they observed "resembles the action/perception coupling observed within mirror neurons" and thus a speaker's activity "is spatially and temporally coupled with the listener's activity" . Through quantitative measuring of story comprehension, they concluded that "the greater the anticipatory speaker-listener coupling, the greater the understanding"-of story. Sharing stories deeply and physiologically connects individuals, something we cultivate over the course of our workshop through a series of small-group story-sharing activities. In addition, guest storytellers model their brainstorming and the writing processes they use to draw on personal experience and identity and craft a meaningful, shareable story. These elder storytellers address the vulnerability and reflect on the questions that arise when transferring one's experience to a narrative, shareable form. "Storying the world" is an active process with choices of many kinds to be made, not a simple act of recording a pre-existing story or narrative verbatim. And, notably, it often requires our storytellers to break out of existing frames and conventions to express their very disdain for self-narrative or the narrativization of life. It is here that the workshop's focus on digital storytelling and feminism and gender studies is particularly pertinent. Digital storytelling-or storytelling that relies on the application of digital software and communication technologies, such as the Internet, for its creation as well as its dissemination and reading-as an emerging, multimodal medium for storytelling, requires creators and scholars to attend closely to the material affordances and constraints that are introduced in these new "writing spaces," to borrow J. David Bolter's early term for digital writing environments . In contrast to print conventions that, over time, seemed to be absolute, transcendent necessities of storytelling, digital storytelling has challenged and upended many of these conventions, like turning pages by moving from left to right as opposed to scrolling down, including only typed language in black font on a white page, or having the text remain stable over time. While digital writing environments, digital cultures, and cyberspace more generally were initially presumed to be liberatory and democratizing to their core, digital storytelling scholars since Janet H. Murray's Hamlet on the Holodeck: The Future of Narrative in Cyberspace , and, more recently, the work of Marie-Laure Ryan and collaborators in her edited collection Narrative across Media: The Languages of Storytelling take advantage of the newness of digital storytelling media as the basis for a comparative understanding of these storytelling technologies as their media-specific expressive capabilities and limits both enable and constrain writing as a result of their material and technological infrastructure and software. For instance, Ryan's typology of media affecting narrativity underscores the spatio-temporal dimensions of digital narratives and their inclusion of multiple sensory channels of communication at once as differentiating features of these narrative media, as in web comics, visual narratives, or interactive narratives, for example. Whereas storytelling in print formats and cultures privileges text and a single, linear narrative movement through time, the workshop story prompts, final project, and guest storytellers engage multimodality to unsettle and question the hierarchical privileging of symbolic language and its alignment with a single, universal, transcendent truth within Euro-American colonialism, which has delegitimized and denigrated acoustic and visual modes of expression and the cultures that revere them. The symbolic register of language and the written word are also gendered masculine and racialized as white within Euro-American colonialist contexts, which initially led cyberfeminist and digital narrative scholars to believe that the introduction of non-linear, multimodal, interactive digital writing environments might equalize the previously gendered roles of the author and the reader. Instead, this heteronormative, cis-gendered opposition is increasingly displaced by more diverse subject positions and identities, and all of these seem further differentiated and delimited, not enabled or empowered by the software and social media platforms on which they rely for their self-writing and storytelling. For this reason, our workshop draws on feminist theories of writing, such as Sara Ahmed's outlined in "Orientations Matter," which understand writing as a resoundingly material and symbolic practice that historically and contemporaneously relies on putting writing technologies and tools designed for others' benefit and uses to your own uses in the best traditions of women's writing from Virginia Woolf's 1929 essay "A Room of One's Own" to Barbara Smith's "A Press of Our Own Kitchen Table : Women of Color Press" . Ahmed and other feminists' attention to the spatio-temporal, material dimensions, and socio-cultural dynamics of writing, if extended to digital storytelling practices, is, likewise, effective in reinforcing the immersive and participatory potential of digital storytelling, whether that is through co-authoring a story online, providing feedback on others' stories, presenting an online story to a live and/or remote audience, or connecting with other people and with geographical sites in real time in ways that impact our perception of space, time, and community. Stories are highly contextual and complex, actively engaging their audiences on cognitive, emotional, affective, interpersonal, symbolic, and cultural levels . By providing these young women storytellers with ample opportunity to choose and combine text, images, video, sound, interactive elements, or kinetics-in one story-and, thus, draw on multiple sensory channels at once, we open up diverse ways for them to express themselves and engage their audiences at all of these levels in transformative ways. In the next section, we describe the structure of the workshop and the materials used to foster storytelling. --- Collaborative Storytelling Approach --- Digital Storytelling Workshop for Young Women The "Gathering Stories" workshop employed multiple dimensions of story work to equip and empower young women as storytellers and as co-creators of their life stories, both individually and collectively. The workshop introduced the young participants to guest storytellers from the Rochester community and historic examples, allowing them to understand and themselves practice story work as a transformative tool for women to reflect on and effectively transform their own lives and communities through self-expression, knowledge, and community building. The workshop 'gathered' young women from across the Rochester area and provided them with an educational stipend of $250 upon successful completion of the workshop. This stipend enabled participation by those hardest-hit by the consequences of Rochester city schools' remote learning during the height of the pandemic and subsidized those who might typically be working through the summer. The workshop also 'gathered' together diverse and differently valued kinds of multimodal digital 'writing,' as equally valuable storytelling methods, focusing on storytellers' development of their own voice through the digital storytelling medium of their choice. --- Workshop Structure Our program is organized as an annual one-week, five-day program, running from 9 a.m. until 3 p.m. daily for a group of 10-18 female-identified high school students. In the first iteration of the program in 2021, our 18 participants worked individually ; in story circles ; and in the full group . Each day was predicated on a theme and broken into several segments to maintain a lively pace. We enjoyed a shared lunch every day as well , where stories were shared in more casual surroundings. Each of the first two days offered a mix of faculty instruction and facilitation of writing and sharing, guest storytellers, longer intensive writing sessions, icebreakers, and exploratory play. Day 3 focused on each participant taking their chosen story and expanding its aesthetic possibilities through the incorporation of media elements . During Day 4 and the first half of Day 5, participants revisioned and revised their projects, and by the afternoon of the final day, they had completed an edited, shareable story. We also ended each day with the participants documenting their experience in a digital reflective journal that the facilitators had access to, which provided workshop leaders with insight into each individual's progress-even their processes of transformation. On the last afternoon, we hosted a story showcase, inviting family and friends to join us for the culminating presentations and story performances. --- Workshop Methods In order to build connections and foster collaboration between young storytellers, we co-authored ground rules with participants that ranged from asking open-ended and non-judgmental questions to being respectful when others express their ideas and to paying attention to non-verbal cues . We prioritized interpersonal feedback and exchange . One of the overarching goals of the workshop was to encourage the group to engage in a practice of radical listening to ensure that reciprocity, care, and listening without judgment remained central to our workshop space and interpersonal interactions. Each day's activities were also linked to elements of the StoryCenter model and its "Seven Steps to Creating a Digital Story: Think It, Feel It, Show It, See It, Hear It, Mix It, Share It" . The "Gathering Stories" workshop goals included: documenting experience; addressing vulnerabilities and empowering positive responses; centering authentic knowledge production; cultivating interpersonal connections; fostering compassion for self and empathy for others; and facilitating speaking, listening, and writing skills. Along with our all-female workshop leaders and student assistants with diverse identities, we hosted guest speakers including an award-winning memoirist, a journalist, and a Ghanaian literary scholar . One important goal of the workshop was to practice documenting experiences-both visual and written-and model respect for diverse storytelling methods and kinds of storytellers. This approach allowed participants to leverage their strengths and attempt a new skill. As one young storyteller's journal entry on Day 5 reflects, "I really enjoyed seeing everyone's stories/projects. I feel as if it's really inspired me and it's making me strive to be better because everyone's [story] was so unique and very well done... I think I've really learned a lot that will help me with my writing for my upcoming college applications and even for other personal creative projects. Sad to go, but so very excited for the future!" This is just one example of the thoughtful journal entries our young storytellers wrote at the close of each day, highlighting what worked well and where they struggled. It was refreshing to see the gradual change in their writing and the deepening of the stories they worked on during the week, as well as to see written confirmation of the rapport that we witnessed in our daily interactions. --- Building Connections with Other Local Teen Storytellers Too often, teens keep their most affecting narratives to themselves, offering less authentic stories in the public arena-or remaining silent. Many Gathering Stories participants initially present as quieter and more introverted and report that they have not found a community of writers and storytellers until our program. Finding a comfortable, safe, in-person social connection remains elusive to many youths. Thus, the workshop design and implementation focus on teen participants developing their own stories. Bringing together students from urban, suburban, and rural regions from a cross-section of different socio-economic demographics as well as a diversity of ethnicities and levels of education and writing experience, Gathering Stories provided a separate space a few paces away from familiar high school social scenes and pressures, allowing these high school women to develop affinities as storytellers without these usual concerns. Emphasizing teens' experiences creates opportunities and presents challenges. In order to create an opportunity for sharing personal experiences, we began the workshop by honoring each participant's initial engagement level and leaving plenty of space for re-orienting and re-visioning as each day, the week, and their storytelling practice and reflection progressed. We asked them to create seed stories to build upon during the workshop and into the future. And we emphasized that although personal writing and self-expression can often be cathartic and the most successful stories are, of course, born out of narrative conflict, there are no expectations that their stories will be those of traumatic life experiences, freeing them to explore a range of narratives, including those that might present as more quotidian, humorous, or low-stakes. --- Results --- Storytelling Successes At the end of the first workshop in 2021, 18 participants completed and shared their final projects, which ranged from a blog exploring crosscultural experiences of food to an experimental documentary film to a comic following the trajectory of a personal passion to a text-image project demonstrating how love can overcome familial challenges. In daily reflective journal entries and in feedback from participants after the workshop's end, the majority of the young women expressed excitement and appreciation for the wide range of writing activities and storytelling approaches introduced over the week, while differing in their preferences. They indicated significant personal satisfaction in completing their story and sharing it at the end of the week, as well as some recognition that this was the beginning of a work in progress that they would continue to develop. As one participant posted on her final project web site, "This workshop brought out confidence in my writing that I wasn't aware that I had in me." A parent of another participant later confided that her daughter "hadn't thought her voice mattered," but the workshop changed that and strengthened her resolve to apply for a competitive college program, to which she has now been admitted. In a journal entry for Day 3 of the workshop, titled "Living on a Prayer," one young storyteller wrote: "This week went by insanely fast... As per usual, today was pretty dope... There were also a few talks that I enjoyed. The exercises were also quite creative. Overall, I think that I've learned a lot, which is great. Now to pray that my project and site turn out well. Video recording time, woohoo!" One young storyteller who had been home-schooled through high school titled her project "Diary of an Insecure Filmmaker," using drawn text and family photos to chronicle her development as a visual storyteller; two years later, she is enrolled in a university film program and determined to become a director. Two participants were attending a Title 1 school in Rochester with 96.4% economically disadvantaged students and 92.5% minority students. One of them wrote an illustrated comic about a young wolf who is scorned by the pack for being "weird." This young woman acknowledged in her final journal entry: "The storytelling workshop may have been a bit nerve racking due to my terrible anxiety but I still loved the experience. There were many things that I did that were out of my comfort zone but I still found the courage to do it because I wanted to learn from this experience. I also did something that I've been meaning to do myself and because of this workshop... express my art through comic form and I loved it." Both of the young storytellers from this Title 1 school returned for a "Spooky Halloween Storytelling Event" we held for young women for the next two years, although one of them has yet to graduate from high school. Several young storytellers also expressed their desire to participate in the workshop again next summer. In the next section of this essay, we reflect on the lessons learned from our first offering of the workshop and discuss the ethical implications of teaching multimodal storytelling to young adults. --- Lessons Learned The age demographic of the workshop's participants means they are digital natives, but there also exists a very real digital divide, exacerbated by the recent pandemic. Not all of our participants have access to a computer at home or internet access, making it difficult for some to spend additional time building on the work completed during the workshop or to experiment with the tools introduced during our daytime sessions. While the grant funding allowed us to offer a program that was both free of charge and provided an educational stipend to participants, some interested students were not able to commit for a full week as they needed to work summer jobs. This is a real-world situation we are working to address. Hosting the workshop on a university campus provided access to various digital platforms to create multimodal stories, expanding writing projects in a way that encourages creative experimentation. The campus, however, is not centrally located, which resulted in transportation challenges for some of our participants, who sometimes were delayed in getting to campus and missed out on some of the activities. The socio-economic diversity of our participants also highlighted differences in writing skills and variances in parental support or caring duties at home. Students who required extra writing help also struggled to complete the homework before the next day's activities, which slowed the progress on their main projects. Prioritizing experiential dimensions of learning and capturing personal experiences through storytelling meant the participants were encouraged to use their smart devices to collect information. Thus, keeping all participants engaged in the radical listening process sometimes became an issue when cell phones instead introduced distractions. --- Discussion Stories are a primary means for individuals and cultures to produce meaning, identify patterns, and transmit these across generations and cultures. From this vantage point, it is no surprise that today we are seeing broad turns toward storytelling, which might be understood as an attempt to ground or stabilize our cultures in the midst of radical change. Yet it is precisely these aptitudes and inclinations to identify and consolidate recognizable, repeatable, and memorable patterns or meta-narratives that can serve simultaneously as a limit and liability to stories in their capacity to calcify, oversimplify, and mislead. The turn to narrative threads like Ronald Reagan and later Donald Trump's "Make America Great Again," for example, is reactive and retrogressive in the desire to return to a wholly idealized, unreal American past, though obviously comforting to many Americans nonetheless. Addressing this conundrum, the philosopher Paul Armstrong usefully situates stories at the crux of our cognitive need to identify patterns while also remaining open to new information and change. He suggests that the complex dynamics of exchanging stories are, in fact, a "two-way, back-and-forth interaction" between the story and reader that might effectively keep "our cognitive processes from congealing into rigid habitual patterns... by holding open their capacity to be reshaped and re-formed" . The legacy of Octavia Butler's fictional The Parable of the Sower and the Parable trilogy, in particular, provide an instructive fictional precedent in this regard . As Armstrong theorizes, stories involve us in the "play of configuration and refiguration," which can "loosen the habitual, ideological hold of any particular set of narrative patterns on our individual and social minds" . Our teen participants are very aware of events, at least at the local and national levels, and their reaction is often to internalize their emotional responses, particularly those that might cause discomfort. A storytelling practice mitigates these tendencies by situating healthy self-expression within a universal milieu that illuminates commonalities and fosters core connections amid differences. While our teen participants are socially aware, they do not necessarily have a strong grasp on the affordances of digital platforms and the implications of sharing personal stories publicly, so demonstrating the power of these tools and practices is a fundamental goal of the workshop. We fully recognize the importance of creating longer-term consistency and engagement by fostering the community we have built over subsequent months, yet there is the ongoing challenge of how to support the Gathering Stories summer participants, especially those from underserved communities, after the program ends. We offered a few workshops and gatherings throughout the year after the workshop , but it was admittedly a challenge of scheduling and funding, and some participants aged out of high school and, understandably, moved on in their lives. Thus, one of our lingering questions is how to expand access to multimodal storytelling tools and provide and grow a space for the creation of stories after the program ends. In future iterations of this workshop and related wrap-around storytelling events, we are considering partnerships with the City of Rochester's Libraries and Recreation Centers so that we can hold half-day storytelling events throughout the school year and make these low-risk and high-access for more young storytellers of all genders. These easy-access gatherings, focusing on flash fiction, horror stories, or slam/performance poetry, would complement our more intensive summer workshop and, we hope, open doors to more young people. We recently launched a web page on the Center for Engaged Storycraft's website to feature our young storytellers and their digital stories annually and archive the workshops, although we are fully cognizant that some of our young storytellers prefer not to have their stories publicly accessible and, therefore, we will ensure consent and keep some stories password protected. With Chat-GPT and other large-language AI models actively pilfering the web, the question of how and whether to publish these young storytellers' work online at all is an increasingly loaded ethical question. In the short term, we intend to educate our young storytellers about Chat-GPT and other large-language models whose predictive learning methods may impact future writing and our understanding of individual creative work and how it should circulate. We will encourage informed choices and explore how generative AI might contribute in the way of brainstorming, audience research, or writing feedback if used with its abilities and blind spots in full view. --- Conclusions In closing, we acknowledge that the ability to take time out to focus on storytelling is a privilege not available to everyone. Creating a collaborative space for storytelling, in itself, is not sufficient, as intersectionality is about structural power, not just multicultural gatherings or identity. The challenges and tensions of gathering young women, families, and educators who remain extremely stratified along racial, economic, linguistic, and cultural lines and have wholly different experiences of American opportunity are a constant concern whose remedy extends well beyond the workshop space of gathering to broader transformations in the community and in networks of storytelling, power, racial understanding, healing, etc. As educators, we recognize that more work is needed to truly co-realize collaborative spaces where universities can work with communities to address larger structural issues in informed ways and foster multimodal storytelling. To this end, we nonetheless remain committed. ---

Digital storytelling prioritizes real-time connections, story creation, contextual adaptability, multi-media expression, and accessibility. This article discusses the unrecognized affordances and value of digital storytelling practices for teens living in precarious (neo)colonial lifeworlds. We review the workshop methods developed as designers and leaders of "Gathering Stories: A Digital Storytelling Workshop for Young Women" in July 2021 to enliven and illuminate high school students' voices while also addressing social, emotional, and affective experiences and needs during the pandemic. The article details how we co-realized spaces where teens' lived experience of gathering and the draw of story were the driving forces for their diverse storytelling practices. Identifying positive outcomes for the first iteration of the workshop, we also identify challenges that will inform future iterations of the workshop, such as structural dimensions of intersectionality and the challenges predicative AI such as ChatGPT poses to such efforts to prioritize experiential dimensions of learning through storytelling.

Literature Review Over a decade ago, the Regional Strategy on Teachers in Latin America and the Caribbean, organized by the United Nations Educational, Scientific and Cultural Organization emphasized the need for a profound renovation of the pedagogical and academic traditions of initial teacher training in the region . This is key to ensure inclusive, equitable and quality education and to promote lifelong learning opportunities for all by 2030 . At international level, especially in Latin America, teacher training has focused on a competency-based model . This professional training model arose in Europe in 1999 , and its extrapolation to other socially and culturally diverse contexts represents a new neocolonial strategy that redresses the epistemic convergence of peripheral societies with the European cultural center . In 2004, the competency-based training educational model became institutionalized in higher education in Latin America through Alfa Tuning Latin America, an international cooperation project, with the aim of standardizing teacher training plans in the region with the European teacher education model in a context of globalization . However, the competency-based training model does not necessarily adapt to the major social and cultural diversity present in Latin American territories since most pedagogy programs do not consider the contexts of social inequality and poverty in which indigenous people live and are brought up, consequently, the Westernized curricular design reveals its decontextualization of educational needs and purposes of indigenous territory . Interculturality is excluded from teaching competencies since it is not an indicator evaluated by the national commissions for the accreditation of higher education in most Latin American countries . Generally, initial teacher training in intercultural perspective is relegated to the goodwill and intentions declared in the mission of universities, despite the centrality of interethnic relations in the social and academic debate in the region . Consequently, intercultural teacher training is not mandatory for most universities in the region. Therefore, it is an invisible aspect in the content of pedagogy programs . This has resulted in the lack of preparation of teachers to meet the educational development needs of minority groups, such as indigenous peoples . However, a more updated perspective on teacher training reveals that this should be configured based on the reality in which organizations and individuals engage . This comes into tension with the paradigm of a globalized world under the Western cultural hegemony, systematized under the competency-based training model . Likewise, this decontextualized training increases structural racism towards historical minorities, continuing with the coloniality of knowing and doing in the formation of trainee teachers. This increases the gaps between indigenous and non-indigenous, since for the latter, higher education becomes a negative space that does not fit their family and community environment . The article has been written in the Chilean region of Araucanía, the ancestral territory of the Mapuche culture, the larger indigenous ethnic group in the country. As teacher trainers and researchers of the pre-service teacher education in a context of social and cultural diversity, the authors seek pedagogical alternatives that allow the incorporation of an intercultural educational approach in pedagogy programs to advance in an epistemological pluralism that progressively favors decolonization of higher education and thus fosters the formation of new citizens from an intercultural perspective. It is assumed that in contexts of social and cultural diversity, competency-based training in educational science programs is based on a monocultural teaching method of a Western Eurocentric fashion which results in the denial and lack of validity given to indigenous people's knowledge and ways of learning in higher education training programs . This assumption is taken into consideration for the analysis of the data extracted from the selected literature. The purpose is to comprise new knowledge that claims for an urgent rethinking of initial teacher training based on the development of intercultural competencies to offer teaching and learning alternatives to account for local diversity, with a strong, rooted sense of social, cultural, and territorial relevance . Consequently, through PTE, Western education systematizes a set of knowledge, procedures, attitudes, and values that attempt to homogenize an increasingly more diverse society . From this analysis, in terms of the development of educational sciences programs in a context of social and cultural diversity, we pose our research questions: Is an educational sciences curriculum based on a competency-based training model compatible with an intercultural education approach? What is a relevant PTE alternative to implement in contexts of highly populated indigenous communities? What competencies can be incorporated into initial teacher training as a transition to an intercultural educational model? Although several studies have highlighted the limitations of the competency-based training model in relation to an intercultural perspective of educational sciences programs , there are few alternative proposals to this training model. In response to the research question above, the objective of this article is to conduct a descriptive-interpretative analysis of the systematized and emerging theoretical assumptions in academic literature, which show hints of a training model based on professional performance as an alternative for teacher training in a context of social and cultural diversity. Its intention is to contribute to the reflection in the current debate associated with PTE from an intercultural perspective. --- Theoretical Framework The reflections and analysis carried out in this article are based on the intercultural educational approach, an academic alternative to the colonizing process of Western Eurocentric pedagogy . In this sense, the underlying coloniality of Western pedagogical traditions standardizes the formation of people under the precepts of scientific epistemology, thereby denying other ways of knowing and understanding the world, such as indigenous lore and their ways of education . As a result, a monocultural process of PTE has been imposed in a context of social and cultural diversity, aligned with the cultural exclusion and social marginalization of minority groups. In the case of the indigenous population, they have developed their own educational rationality . Conversely, an intercultural educational approach contains an analytical and critical aspect that questions cultural domination and social injustice imposed by Western culture in indigenous contexts by means of the competency-based training model . In this sense, some studies have argued the urgency of decolonizing teacher training in contexts of large indigenous populations. The current article is an attempt to promote the intercultural educational approach in Chile, a model of education that values and respects cultural, ethnic, and linguistic differences of all students . Also, it progressively incorporates other views into the training of the new generations, such as indigenous educational contents and views to understand the world . Likewise, it promotes incorporating indigenous educational methods such as learning by doing, observing, listening, and inquiring about family members and the community to transmit knowledge . From an intercultural educational approach, it seeks to offer a relevant training process from a sociocultural point of view for children and young people based on the educational needs and purposes of their respective territories . This argues in favor of including the history, culture, and languages of indigenous peoples in the educational curriculum, as well as the promotion of equal opportunities for students of different cultural backgrounds, progressively reversing the educational gap between indigenous and non-indigenous students in higher education . However, advances in educational policies in Chile have remained disconnected from initial teacher training . So, inequality and discrimination towards indigenous peoples, such as the Mapuche, continue to be installed in the curricula of pedagogy programs in higher education and the teachers' rationale . In recent years, there has been a greater emphasis on implementing the intercultural educational approach in Chilean schools, especially in rural areas and indigenous communities . At the same time, a latent challenge in the country's educational policy is to guarantee that in regions with high indigenous demography, such as the Araucanía region, teachers should be trained in pedagogical skills to understand and value other rationalities other than the Western one, such as the Mapuche culture that has struggled to survive and develop . However, indigenous rationalities, such as the Mapuchean one, continue to be excluded from higher education in Chile, especially from the PTE process . The lack of an intercultural educational approach in the educational policy of Chile is a consequence of the imposition of the training model in pedagogy programs that denies the epistemic value of the social, cultural, and linguistic diversity, typical of a globalized world . PTE is understood as the first stage of professional development, in which teachers in training acquire a set of teaching, disciplinary, methodological knowledge, skills, values, and cultural models associated with the requirements of the social context in general and the school institutions, which precede the professional performance stage . However, Westernized professionalization of educational sciences programs has turned PTE into a positivist and utilitarian process, through which learning scientific and methodological material related to education must precede the development of practical skills for teaching . In this positivist, hegemonic and monocultural pedagogical framework, competency-based training is presented as the ideal model for the professional training of teachers, regardless of the cultural identity of the actors involved. The current model implies professional training in ignorance of the characteristics of sociocultural diversity of the children and young people that trainees might educate in the future . This current situation hinders training of future teachers in pedagogical and intercultural skills . The term competency arose in the educational realm in the mid-20th Century, when the production and academic frameworks began to question whether the use of intelligence tests, ranking of scores from positivist evaluations and the level of schooling reached would successfully guarantee insertion of people into the job market . The competency-based training approach is based on the dynamics of job training, which diminishes the prominence of higher education in holistically training professionals for the structural change of society . In consequence, competency-based training in a context of social and cultural diversity has been conceived of as an essentially practical scientific , hegemonic, and professional education, based on work and action , in which diversity is negated or unseen . It is questionable whether the competency-based training model for educational sciences programs promotes a professional preparation that is relevant to the context, or whether it alternatively inhibits teacher autonomy . --- Methodology The study has a qualitative paradigm since the research focuses on understanding and explaining the process of formation of pedagogical competencies in the context of social and cultural diversity through the interpretation of the data obtained in an in-depth review of the state-of-the-art literature. Thus, the research consists of a systematic literature review which is a rigorous method of collecting and analyzing previous studies on a specific topic to identify trends, patterns, or common conclusions in existing research . This survey of scholarly sources provides an overview of the research problem. The findings were organized and coded through a qualitative content analysis since it is a data analysis technique used to understand the meaning and context of the data . To conduct the study, a varied, significant, and sufficient literature was selected that allowed the construction of a decolonizing theoretical framework regarding the PTE process in the context of social and cultural diversity . The selection of the literature and codification of the information was carried out in five steps. --- Selection of Varied Literature The selection of studies from different authors, methodologies, and theoretical approaches allows for a more complete and objective perspective on the topic in question . The criteria for selecting varied literature are: a) to include studies from different authors and countries, b) to select studies with different theoretical and methodological approaches, peer-reviewed, c) to include studies published in different internationally recognized databases, d) to include studies with contradictory results in order to be able to analyze the differences and similarities between them. As a first step, a literature search was conducted in Spanish, English, and French with the following keywords: intercultural competencies, initial monocultural training, curriculum design, initial teacher training . The literature consulted is of local, national, and international scope. This ensures that the selected articles address the topic of interest from different cultural perspectives and from different scientific positions . In this step, 328 texts were selected. --- Selection of Relevant Literature The selection of relevant and significant studies allows obtaining more accurate and reliable results . It is important to obtain results based on the available scientific evidence . Criteria for selecting significant literature include: a) to select up-to-date studies on the topic, b) to include studies that present novel results in the field, c) to select studies that use rigorous methodologies and clear methods of data analysis, d) to prioritize studies published in the last 5 to 10 years. As a second step, most of the selected literature is indexed in the Scopus database, a globally recognized data archive that applies rigorous procedures for the approval and publication of scientific studies . Scientific papers published in other databases, peer-reviewed or conducted by recognized authors on the object of study were included in the selection. The search is conducted after 1973, as this year marks the first academic publications on the competency-based training model. However, in the search strategies, priority was given to the selection of recently published literature. In this step, the number of selected articles was reduced to 173 texts. --- Selection of Sufficient Literature The selection of sufficient literature minimizes a bias in the selection of studies and increases the validity and reliability of the review, which in turn increases the reliability of the results obtained . As inclusion criteria we established theoretical saturation of the emerging categories. As a fourth step, after the literature was selected and examined, summaries of the most relevant articles and texts were written down . The summaries were evaluated by two reviewers working independently using include, exclude, or maybe as evaluation options. Choice conflicts were resolved in reviewer team meetings by inviting an expert as a third party to ensure that there were no threats to validity. In this step, the literature selection was reduced to 97 academic, scientific texts. In the fifth step, the literature review was organized around the description of three areas of PTE: teaching, research, and practice until the theoretical saturation of the content was reached . As a result of this last step, 55 academic, scientific texts were selected for the systematic review. They are referenced at the end of this article. --- Coding of Information Coding is the process of identifying significant themes or patterns in the data collected during qualitative research . It is a process of analysis that involves examining the content of the data and grouping it into thematic or conceptual categories that reflect the main ideas or themes that emerge from the data . The coding of the information is carried out as follows: data processing, conceptualization and interpretation of the data, and discussion of the findings. --- Data Processing The first step in the coding of the information was to identify the key concepts that emerge from the data and that allow us to have a first approach to understanding the object of study . The coding of the information was carried out with the help of the Atlas.ti-9 software. This software allows that, once the selected documents have been entered, the data can be segmented into units of meaning in accordance with the objective of the study. This software reveals data in the form of networks of key concepts. First, a list of key words, phrases, and concepts related to the objective and research questions was made. The significant phrases were organized according to their meanings into groups of common content called codes . For reasons of space, the list of codes is not included in the article, they are implicit in the discussion section. The codes were regrouped according to patterns and relationships between them into subcategories . Subcategories possessing the same meaning were grouped into new units of meanings of a higher order of abstraction called categories . The emerging categories were interpreted as the professional performance guidelines applicable to initial teacher education in an indigenous context. --- Conceptualization and Interpretation of the Data During the development of the system of codes, subcategories, and categories, the researcher goes in a constant back-and-forth reading and coding of the data . In that sense, as a second step of coding, links among sets of data were established to group them into thematic networks . This search for common denominators involves thinking procedures: induction-deduction and analysis-synthesis . The study of the competency-based training model starts deductively, i.e., it is carried out from the general to the specific . This occurs because general statements based on existing theory are applied to the specific circumstances of initial teacher education in an indigenous context . Parallel to deduction, inductive inferences were made . In that sense, the analysis of the information moves from the specific to the general . This type of argument has as its starting point the accumulation of many specific events or similar cross-cultural PTE experiences to identify, based on the repetition and likelihood of the collected data thematic patterns and emergent categories . Inductive and deductive inferences from the data indicate that the professional contents of pedagogy programs are of little relevance to intercultural teacher education in the context of social and cultural diversity. Therefore, comparing the competency training model systematized in the literature with the facts of initial teacher training in the context of social and cultural diversity revealed the urgency of deepening the logic and content of a model of initial teacher training based on intercultural professional performance. At the same time, the analysis-synthesis of the extracted data was carried out. The analysissynthesis consists of the organization, classification, summary, and interpretation of the selected information . The gathered information was broken down into three areas of PTE: teaching, research, and practice, to go deeper into each area of professional training. As a result, irrelevant concepts for the study were eliminated, and the data sample or simplified into smaller units of importance. Then, through synthesis, the integration of information takes place without juxtaposing the analyzed data to make the units of signification extracted from the text as meaning . The analysis-synthesis has been fundamental to capture in depth, the richness and diversity of meanings systematized in the documentary sources consulted that indicate the importance of including intercultural professional performance in PTE. --- Discussion of the Findings Finally, as a third step, the theoretical triangulation of the three areas of PTE: teaching, research, and practice . The triangulation allows mapping the emerging qualitative relationships , which characterizes the modes of intercultural professional performance. In that sense, the theoretical triangulation allowed the discovery of ten subcategories, which were grouped by the theoretical affinity, in three categories of a higher level of abstraction : development of intercultural critical thinking, autonomous search for intercultural knowledge, and intercultural communication. As a result, a conceptual framework was developed to synthesize the relationships among codes, categories, and subcategories identified in the qualitative systematic review. This conceptual framework helps explain the results and provides a solid basis for understanding the object of the study . --- Critique of the Monocultural Educational Sciences Curriculum in an Indigenous Context Most of the definitions of the term professional competency agree on relating this to the accumulation of professional contents: conceptual , procedural , and attitudinal , which the competent individuals can activate to optimally resolve situations and problems that are specific to their work profile . PTE professional content is part of the pedagogical cultural background transmitted to teachers in training from diverse sources , which is appropriated throughout the course of the degree program . The conceptual contents are associated with the system of knowledge that must be mastered by the subjects training to be teachers . The procedural contents are associated with the system of skills, habits, actions, procedures, problem-solving methods that the agents in training structures around the value placements they make on their social and cultural environment such as: values, interests, convictions, feelings, and attitudes, out of which decisions are made . Teachers are competent when they are capable of mobilizing and integrating all these cognitive resources, capacities, and practical skills to efficiently face determined situations in their professional performance . The professional content in the curricular framework responds to these questions: What to teach? What to learn? . The answers to the previous questions urgently demand a rethinking of the professional content of teacher training programs, considering the diversity of outlooks, points of view, and different identities in existence in the context of training . A summary of the main competencies implemented in PTE is as follows: a) Cognitive competencies, associated with pedagogical and disciplinary knowledge of the subject taught . Generally, this type of competencies is biased by scientific knowledge, so that indigenous knowledge is generally excluded from the professional content of PTE . This results in cognitive competencies that do not fit the ways of teaching and learning styles historically developed by indigenous peoples . b) Metacognitive competencies, associated with the development of reflective, critical, and self-critical thinking about pedagogical work . Generally, in Western culture the development of teachers' metacognitive competencies is based on the understanding of Western reason and logic that ignores the indigenous vision of a holistic and integrated world . In that sense, metacognitive competencies are directed to the development of an individualistic conception of professional performance, without taking the community and cultural dynamics, which affects learning process of indigenous students . c) Social competencies related to communication, participation, and knowledge of the educational environment . These competencies are developed by teachers in training from the Western perspective of power hierarchies . This causes student teachers to conceive their teaching work as a linear and hegemonic act of communication, without valuing the pedagogical importance of other forms of pedagogical communication such as dialogic or symbolic, typical of indigenous cultures . In this way, the forms of education developed by indigenous families, which are based on close and horizontal relationships among people, are made invisible in initial teacher training . d) Competencies to plan and organize the teaching and learning process . These competencies are centered on a linear and homogeneous conception of teaching, which does not take specific learning styles of indigenous individuals into account . Therefore, teachers in training develop competencies such as the design of standardized lesson plans, selection of teaching materials and evaluation types. This standardization does not integrate the specific needs and realities of indigenous contexts into teaching . It also hinders inclusion and equitable education for all students. Consequently, the competency-based model has no intention of promoting the contributions of the indigenous worldview to understanding the world and the education of people as part of PTE . Thus, the model of training by competency, by not projecting an inclusive vision towards the whole of society, constitutes a mechanism of social control through which the dominant culture has historically determined an ideological orientation of education to legitimize itself in power . On the other hand, from an intercultural and critical standpoint, Ferrada and Flecha maintain that curricular design is a social construct contextualized to the teaching and learning requirements defined by the people who make up an educational community, through multiple sociohistorical interactions of power and dialogue. These ideas distance the PTE process from the standardization imposed by the competency-based training model and place it in a process of interpretation of experiences, which in a context of social and cultural diversity are necessarily different from Westernized ones. From this perspective, we must urgently reinterpret the PTE process in a context of social and cultural diversity, in terms of the connections and tensions that occur between people in the exchange of meanings from culturally distinct positions. From this perspective, UNESCO and the Organisation for Economic Co-operation and Development maintain that PTEbased on intercultural developmentis essential to ensure that future professionals be capable of developing professional performance methods that are consistent with diversity in teaching and learning processes in a region which those demographic characteristics. Another limitation of the competency-based training model in context of large indigenous populations is the fragmented position of pedagogical and disciplinary knowledge in the training itinerary, through the areas of professional education: teaching, research, and practice . This is an educational conception that equates to the Westernized cultural vision in terms of understanding the world, which is transmitted to new generations through education and especially through teacher training. Consequently, the central focus of the teaching area of curricular design is the acquisition of theoretical, disciplinary, and normative knowledge of the teaching profession . The priority in the competency-based training model is scientific knowledge . Therefore, learning the conceptual contents of the disciplines, their methodologies, and procedures becomes a hegemonic approach where the professional content excludes the ecology of types of knowledge that could be present in the training context . Furthermore, the historical teacher-student relationship in intercultural contexts has been sustained by a hegemonic hierarchy of the teacher towards the subjects in training , through the transmission of scientific knowledge as the only civilized option for understanding the world . However, for Zabalza , pre-service professional education is a process that encompasses more than learning disciplinary content, to integrate a much broader set of capacities, dispositions, and attitudes. The, according to Larochelle-Audet et al., , demands that educational sciences programs train teachers to learn to act in a particular context. For this reason, the urgency of training teacherswho might work in contexts with large indigenous populations in professional performance calls for the development of intercultural critical thinking. This is why some scholars, such as Freire , have supported the feasibility of adapting the teaching and learning process to the social, historical, and cultural characteristics present in the school context, favoring the emancipation of children and young people having a strong sense of sociocultural belonging. At the same time, this process of adaptation might give them tools to develop in a globalized world. In the competency-based training model, the research area is associated with the ability to discover and interact . This is significant in the acquisition of new knowledge on education and its practices within the framework of educational interactions . However, the barriers imposed in academics to intercultural dialogue have meant that, historically, in the curricular framework of educational sciences programs, research competencies from an intercultural perspective have been overlooked . For this reason, the PTE process in indigenous educational contexts should encourage teachers to autonomously search for intercultural knowledge, a way of professional performance that provides teachers with tools to handle intercultural problems that emerge in contexts of sociocultural diversity. In the competency-based training model, the area of pre-professional practice involves the interaction of the subject in training with the object of the profession . This is the most professionalizing curricular area in curricular design . According to Shulman , this is about the knowledge obtained from the practice itself . In this sense, the teacher appropriates learning to do in education that is based on two components. The first has a theoretical nature associated with the disciplinary and professional domain, which in essence is knowledge, and the second component comes from the practice itself, the operative, spontaneous, and dynamic element, knowledge in action . However, according to Quilaqueo et al., , the competency-based training model does not prepare pedagogy students in pre-professional practice to communicate and interact with indigenous students, their families, and the community in their native languages. The preceding demands that pedagogy students be trained in indigenous customs and languages and professional performance to allow them to establish appropriate intercultural communication in the indigenous educational context . The issue raised so far confirms that curricular design in educational sciences responds to the question posed by Sleeter : What is the perspective from which we want to teach students to see the world and to see themselves in the world? . The answer, within a framework of a culturally and socially diverse society, places pre-service teacher education at the crossroads of the conflict between the hegemony of occidental teaching and the interpretation of life experiences in context . --- Figure 1 Relationships between the Competency-Based Training Model/Professional Performance Training Model Note. Author's own elaboration, with the help of the Atlas.ti-9 software. --- CONTEXT LABOR MARKET --- COMPETENCY-BASED TRAINING TRAINING IN INTERCULTURAL PROFESSIONAL PERFORMANCE contradicts is a property of This dilemma challenges institutes of higher education to rethink the day-to-day modes of learning to know and learning to do enclosed in the competency-based model of teacher training programs, to move towards other forms of intercultural knowledge , relevant to the diversities of the training context . Historically, however, institutes of higher education have been known to make cultural differences invisible in professional training processes . In this sense, the logic and content of a training model for teachers based on intercultural professional performance will be delved into in the following section. --- Training in Intercultural Professional Performance From a constructivist , critical , and intercultural standpoint , PTE curricular designs in a context of social and cultural diversity must integrate relational content to conceptual, attitudinal, and procedural content . In the curricular design, relational content includes the system of interactions of people with the natural and social world, where these are associated with learning to live together, learning to understand, and learning to connect . When it takes on a professional character, this content expresses the awareness, knowledge, understanding and sensitivity that the graduate demonstrates towards other cultures that are epistemically different from Western culture . However, this type of content is usually absent or minimal in most educational sciences programs . According to Fougere , teacher training in intercultural professional performance is composed of five main components: 1. Intercultural point of view and approach, which implies being able to be oneself based on one's own frames of reference . This implies the development of an attitude of epistemic openness, to address and discover other ways of understanding the world from one's own frame of reference in articulation with other culturally different frames of reference . 2. Knowledge , which implies knowing the different social groups in interaction, their products and their practices, awareness of their interactions between society and individuals; this includes knowledge about intercultural theories and different cultures context . --- Mutual understanding , which implies putting interpretations into dialogue based on the subjective and intersubjective meanings and standards of the sociocultural frameworks in interaction ; a way of systematizing knowledge about one's own culture in epistemic articulation with other frames of reference that interpret natural, spiritual, and social phenomena differently . 4. The ability to discover and interact , to acquire new knowledge about a culture and its practices, making it possible to negotiate different points of view and aptitudes within the framework of real-time communication and interaction . It is essential for teachers to develop skills that allow them to put into practice diverse learning strategies from other cultures, promoting analysis and selfanalysis to respond appropriately in a context of social and cultural diversity . --- 5. The capacity for critical vision , which refers to the ability to critically evaluate points of view, practices, and products in one's own frame of reference with other frames of reference in interaction . Burgess found that teachers who have been trained in intercultural professional performance feel more confident and willing to engage in educational relationships with indigenous peoples. From this perspective, PTE becomes a multilateral learning process, in which future teachers learn to coexist with other teachers and students with epistemic frameworks other than the Western framework, learn from them, and assimilate new individual and collective responsibilities in the face of diversity . Consequently, professional performance methods acquire an intercultural character when they enable teachers to establish appropriate and effective relationships with knowledge, worldviews, and people with different cultures. In short, training and development of intercultural professional performance methods in teachers enable education in the context of social and cultural diversity to respond to two big challenges for sustainable development. The first is associated with ensuring access to equitable quality education and lifelong learning for all . The second refers to an awareness of the importance of social and cultural diversity without hierarchy, where individual experiences are valued and promoted . From the previous analysis, this study raises the intercultural professional performance methods that are most frequently discussed in scientific productivity in relation to PTE. --- Results and Discussion Fifty-five texts were selected for the study. Forty-two scientific articles were included, representing 76.36 % of the selected literature, of which 69.05 % were published in the Scopus database, the rest of the articles were indexed in other peer-reviewed databases. In addition, seven books published by authors widely cited in the research topic and one doctoral thesis report were included. This means that the consulted material has been validated by experts. In addition, five reports or articles published on the websites of relevant international organizations were selected to support the social significance of the study. Of the 55 titles included in the review, 40 texts have been published in the last 10 years. Thus, 30.91% of the total number of systematized references are between six and nine years old and 41.82% are less than five years old. This has made it possible to identify the current state of research in the field, epistemic gaps in theory, and emerging trends. It was found that qualitative methodological approaches prevail in the research community in relation to the formation of teaching competencies in the context of social and cultural diversity. Therefore, results consulted are influenced by the subjective perspective of the authors. Nevertheless, three studies with a quantitative approach and three with a mixed methodological approach were included, which provides a point of comparison. Although the search was carried out in international databases, 14 studies of local and national scope were included, which shows the contextualized perspective of the problem in a globalized world. The main findings of the study are discussed below. After applying the theoretical triangulation to the content of the three areas of PTE, namely teaching, research and practice , information is graphically represented . It was known that, in the context of social and cultural diversity, the content of the areas of professional training interacts in the curricular design in a logic of unity and reciprocal opposition among them . --- Figure 2 Map of Qualitative Relationships between Professional Training Areas Note. Author's elaboration. Consequently, the dynamics of the initial teacher training process in indigenous context provokes methodological , epistemological and ontological interactions of a transdisciplinary and holistic nature in which it is important to delve deeper. The theoretical triangulation of the content of the three areas of PTE revealed three categories which are latent in literature: development of intercultural critical thinking, autonomous search of intercultural knowledge, and intercultural communication, which are interpreted as useful professional performance for the initial training of teachers in the context of social and cultural diversity. --- Category 1: Development of Intercultural Critical Thinking This first category emerges from the epistemological and transdisciplinary relationships between the areas of professional training for teaching and research. Undergraduate teaching is the training area associated with learning to know and learning to be because this is where an individual learns to feel the profession and build a professional identity . In the training model in intercultural professional performance, student-centered learning is prioritized in undergraduate teaching . Under this concept, subjects in training are responsible for their learning and the development of their professional skills . However, historically in the field of Western monocultural teaching, academics have sustained their formative influences within the framework of disciplinary teaching, which has limited students' construction of educational meanings associated with other logics of understanding the world, such as indigenous worldviews . Teacher training in intercultural professional performance implies transmitting a diversified set of knowledge to future teachers, both in terms of skills and intercultural strategies, to conceive of teaching and learning situations with social, cultural, and territorial relevance . --- Table 1 Development of Intercultural Critical Thinking Definition of the category Subcategories The development of intercultural critical thinking is a social practice through which individuals develop epistemic curiosity to understand the position of another person in juxtaposition to their own, by giving meaning to situations in daily life . It is a way to develop intercultural curiosity, by trying to analytically examine the relations of oppression and inequality that have historically been legitimized through education and PTE . This category is associated with learning to connect. --- Epistemological pluralism Self-training in the knowledge of the profession --- Autonomy capacities --- Questioning power relations Undergraduate teaching linked to the research of teaching, experiential and methodological knowledge of epistemological plurality favors the development of intercultural professional performance . Therefore, the undergraduate teaching-research relationship is the fundamental epistemological combination for teachers in training to develop the professional performance method of intercultural critical thinking . Intercultural thinking is associated with teaching epistemological pluralism . Harvey and Russell propose the formalization of an intercultural curriculum raised in neutral terms that trains teachers in the creative selection of educational content based on the articulation between indigenous knowledge and the understanding of scientific knowledge. This is an aspect that still represents a challenge to higher education in Latin America . Extrapolating from Freire , the development of intercultural critical thinking is a means of lifelong reflective learning, which requires the development of professional autonomy and self-training capacities. Consequently, Chilisa argues that intercultural critical thinking is based on the understanding and recognition of one's own culture and the culture of the others through research into educational reality to understand the effects of these intercultural relations. This can be achieved through dialogue and reflection with subjects who have been placed in a subaltern status to then build common knowledge . Professional action based on critical ways of thinking questions hegemony and social inequality rooted in contemporary society, which has historically conditioned the construction of meanings in the educational system . Teachers are expected to become empowered as agents of educational change to promote the shared wellbeing of the most dispossessed, such as indigenous peoples. --- Category 2: Autonomous Search for Intercultural Knowledge This category emerges within the framework of methodological and transdisciplinary relationships between the areas of research training and pre-professional practice. In the training model in intercultural professional performance, the research area contributes to the appropriation and development of autonomous and innovative professional performance, which allow teachers in training to learn to solve professional problems that arise in the classroom, applying acquired knowledge to new situations . It is possible for the subject in training to critically reflect on and research their own professional practice . Therefore, curricular relationships between the areas of research training and pre-professional practice are relevant for future teachers to learn to build a tailored educational intervention that considers the sociocultural relevance of the other . It is within the framework of intervention in intercultural educational practice through research that intercultural professional performance is formed in teachers: autonomous search for intercultural knowledge. --- Table 2 Autonomous Search for Intercultural Knowledge Definition of the category Subcategories The autonomous search for intercultural knowledge seeks to provide teachers in training with the set of knowledge, skills, and values needed to search for information on new methodologies and teaching resources for independent construction through reflection in and on educational action, of new knowledge in context that provides answers to problems that emerge in the intercultural classroom . This mode of intercultural action is associated with learning to understand . --- Training based on professional problems --- Learning in context --- Co-construction of educational knowledge The autonomous search for intercultural knowledge is associated with learning to understand, which requires teachers in training to learn to get involved in the social diversities of all their students, indigenous or otherwise to interpret the origin of intercultural tensions that may arise in an educational arena . Thus, PTE based on the autonomous search for intercultural knowledge helps teachers in training to continually develop the ability to learn to learn, learn to educate, and learn to research, or put another way: learn to make the act of instructing relevant and to educate in a context of social and cultural diversity . For this, it is necessary to focus on training based on professional problems . The pre-professional practice of teachers in training can focus on the research of some professional problems such as: a) the need to characterize and diagnose students, the group, the family and the community environment in diversity , b) the search for intercultural procedures and alternatives that stimulate plural learning in indigenous and non-indigenous students , c) school evaluation from a bias of Western pedagogical rationality , d) the coordination of predominantly Western monocultural educational work with culturally diverse educational stakeholders and community leaders . It is also important to identify the dynamics of rejection or isolation that can affect children and young people who come from vulnerable social contexts, such as indigenous communities . It is important to note that training based on resolving professional problems prepares teachers in training to teach indigenous and non-indigenous students to identify and resolve difficulties that affect relationships between people with different cultural origins . In addition, Fickel et al. reports that the autonomous search for intercultural knowledge demands learning in the context of professional content. Learning in context consists of the mobilization and integration of epistemic, cognitive, methodological, and practical resources into professional work with a sense of social, cultural, linguistic, and territorial belonging . Consequently, it is important that the search for information carried out by teachers in training is developed through horizontal epistemic relationships with actors from the intercultural social environment . In other words, through the co-construction of knowledge with fathers, mothers, elders, and other preponderant indigenous stakeholders in the territories where training takes place . Kristoff found that the co-construction of professional knowledge develops a respectful representation of indigenous knowledge in subjects in pre-service education and contributes to reducing cultural gaps between people of different cultures. Ibáñez-Salgado and Druker-Ibáñez found that to the extent that teachers in training are able to autonomously delve into the co-construction of intercultural knowledge, they develop the ability to constantly reconstruct new meanings in relation to diversity and their profession. Hansen et al. found that, by co-constructing knowledge with the elders from an indigenous community, educational sciences students developed transformative learning outcomes in a spirit of collective reciprocity. This enabled them to consolidate skills to develop relationships of trust and mutual respect with other people. As a result of this, the autonomous search for intercultural knowledge is an intercultural professional performance method that helps future education professionals to develop greater sensitivity toward issues that affect indigenous cultures. It is also a way to learn the role of cultural mediator that falls to teachers in intercultural school contexts. --- Category 3: Intercultural Communication This category emerges from the ontological process associated with the system of influences that teachers in training receive through undergraduate teaching, which they interpret and then transmit to new generations through pre-professional practices. In the intercultural professional performance training model, the area of pre-professional practice is of vital importance so that future educators can appropriate professional performance methods and procedures that allow them to adequately handle problems and situations in a space of social and cultural diversity . Therefore, training to be a teacher implies the development of learning to connect and learning to live together based on a symmetrical educational relationship between oneself and the other . This is achieved through dialogue, through intercultural communication . Intercultural communication implies using education to create a dialogue on the multilateral relations between the teacher-student/student-student and between these and other social stakeholders , based on the subjective and intersubjective meanings and standards of the sociocultural frameworks in interaction . Balakrishnan et al. found that intercultural communication between subjects from different cultures facilitates cooperation between them by promoting mutual understanding in contexts of respect, appreciation, and acceptance of the other from a global and local perspective. Development of the intercultural communication professional performance method is associated with the contextualization of teaching, an aspect that requires teachers in training to have the ability to acquire and assess knowledge, educational traditions, and worldviews of the indigenous world . The pre-professional practice, as a formative element of the intercultural communication professional performance method, challenges educational sciences students to distance themselves from their own culture and be attentive to misunderstandings and erroneous interpretations that can emerge in the context of interaction with subjects belonging to different cultures, such as indigenous students. According to Heyman , the intercultural communication professional performance method implies a paradigm shift to advance the knowledge of the other's culture, to come to share the general values of humanity and the specific values of indigenous peoples in a shared sphere of action. However, for teachers to appropriate intercultural professional performance, it is important to use teaching methods associated with educational traditions, customs, and worldviews relevant to the training context in undergraduate teaching activity . --- Table 3 Intercultural Communication Definition of the category Subcategories Intercultural communication implies training future educators to interact through intercultural dialogue with subjects from different cultures , based on negotiation and mediation processes of the heterogeneous cultural knowledge that enters the interaction . This implies being able to put oneself in the place of the other as a legitimate other, to build multi-referential knowledge . This is associated with learning to live together . --- Development of shared attitudes and behaviors --- Systematization of intercultural dialogue --- Contextualization of teaching Teaching methods have an instructive function and an educational one . Consequently, Quilaqueo et al. found that where the importance of intercultural methods for education is valued in PTE, significant modifications are produced in the perceptions of the actors in training regarding the meanings of indigenous educational knowledge for education. In this sense, the use of dialogical methods in PTE is essential for the development of intercultural communication in teachers in training, since language acts as a significant mediator between the context and the creation of meanings . Thus, the construction of the intercultural communication professional performance method becomes a social space that counteracts the monocultural linearity of the educational sciences curriculum in the context of social and cultural diversity. --- Conclusions The study concludes that the competency-based teacher training model in the context of social and cultural diversity must move from a Westernized monocultural conception that negates the logic of indigenous knowledge toward a comprehensive assessment of interculturality as a positive element that generates professional performance in teaching that is relevant to diversity. Courses of action include the urgency to redesign the educational sciences curriculum to promote a pre-service training focused on the acquisition of knowledge, skills, and values that develop critical intercultural thinking in teachers in relation to the social and educational reality. This would make PTE a link between the social, cultural, and technological demands derived from globalized intercultural relations and the aspirations of equity, equality, and diversity of the most vulnerable people. --- Disclosure Statement No potential conflict of interest was reported by the author.

The purpose of this article is to conduct a descriptiveinterpretative analysis of the systematized and emerging theoretical assumptions in academic literature in initial teacher training, which show hints of a model based on professional performance as an alternative in contexts of social and cultural diversity. The article is based on an intercultural educational approach which has an indigenous perspective. This raises the urgency of rethinking teacher training processes in relation to indigenous and intercultural contexts based on appraisal and respect for indigenous children and young people's episteme, who hold cultural, ethnic, and linguistic differences. This article discusses the main limitations of the competency-based training model in educating teachers who take on inclusion and diversity of indigenous individuals as part of their professional performance. This research is qualitative and is grounded on content analysis of literature selected from internationally renowned databases. The literature review was organized around three areas of professional education: teaching, research, and practice. Results taken from this search were interpreted from the perspective of the educational model of the universities of the Araucanía region, Chile. An intercultural context that is characterized by a high enrollment of students from indigenous and rural communities. Results show associations among conceptual, attitudinal, procedural, and relational contents in professional training areas that might be subject of reconceptualization, this is, to enlarge the scope in the initial teacher training model by including intercultural professional performance in the context of social and cultural diversity. These areas fall into three categories: (a) development of intercultural critical thinking, (b) autonomous search of intercultural knowledge, and (c) intercultural communication, which are interpreted as useful for professional performance and are highly recommended in literature for their inclusion in educational sciences curricula.

The novel coronavirus disease 2019 threatened the health and well-being of all families, with a disproportionate impact on families of children of color . In response to COVID-19, health care systems restricted and/or postponed in-person clinical appointments, with many rapidly implementing telehealth, including virtual, remote, and telemedicine services . These health care system-based disruptions in diabetes care can present a challenge to youth with type 1 diabetes and especially for Black and Hispanic youth, as they are more likely to miss appointments and have suboptimal glycemic levels compared with White youth . The effectiveness of telehealth-based care for diabetes management during COVID-19 is promising given the availability of sharing electronic data from advanced diabetes technology devices . Indeed, research conducted before the pandemic found that the use of telehealth in type 1 diabetes management resulted in improvements or no change in A1C levels over the course of 1 year and that patients were generally satisfied with telehealth, although some reported technical issues . Unfortunately, a successful telehealth encounter requires reliable Internet access, a device with audio and video capabilities, and digital literacy, which are common challenges for communities of color that are disproportionately affected by the digital divide . From the available studies conducted during the COVID-19 pandemic, it appears that attendance rates among patients with type 1 diabetes were similar for telehealth and in-person appointments, demonstrating engagement with telehealth . Two pilot studies also found that people with type 1 diabetes who attended telehealth visits during the pandemic showed improvements in glycemia, signaling potential effectiveness . However, survey data collected during the pandemic revealed a range of perspectives regarding acceptability, feasibility, and preference for telehealth , suggesting that more research is needed to understand families' lived experiences of telehealth during COVID-19. Before the pandemic, adults with type 1 diabetes expressed concern in qualitative interviews that, over time, telehealth would undermine their expertise in managing their diabetes by shifting control to their health care professionals . They reported problems electronically transmitting clinical data and receiving meaningful feedback because of limited staff time and asynchronous support, and they emphasized face-to-face contact as being key to quality care . This study on adults provided some insight into patients' perceptions of telehealth for type 1 diabetes care, but a pediatric perspective is still lacking. Pediatric populations have additional factors to consider when using telehealth . More importantly, there is a need to document the lived experiences of youth of color with type 1 diabetes, a group at greater risk of suboptimal health outcomes and disproportionally affected by the digital divide . Such information may improve the quality of pediatric diabetes care delivered through telehealth as the pandemic persists. Pre-pandemic, diabetes HCPs felt that telehealth was generally acceptable and had clinical benefits . However, they also identified several concerns such as a lack of personal contact and families being unfamiliar with technology . Despite these findings, it is imperative to obtain HCPs' perceptions to gain insight into unique facilitators of and barriers to delivering pediatric type 1 diabetes care through telehealth during COVID-19. To address these gaps in the literature, the aim of the current study was to gather perspectives from youth of color, their caregivers, and HCPs on telehealth for type 1 diabetes care during COVID-19. --- Research Design and Methods This study was conducted as part of a larger qualitative project approved by the Nemours institutional review board . This larger project examined facilitators of and barriers to advanced diabetes technology use for type 1 diabetes among families of color, initiated in June 2020. Consistent with best-practice guidelines for health disparities research , the larger study included a stakeholder advisory board composed of two youth of color with type 1 diabetes and three caregivers who contributed to the research question, recruitment procedures, and interview guides and reviewed the final qualitative findings. --- Participant Recruitment Youth of color with type 1 diabetes between the ages of 12 and 19 years who had been diagnosed at least 12 months before recruitment, did not identify as non-Hispanic White, and primarily spoke English or Spanish were eligible to participate. Caregivers of eligible youth were also invited to participate regardless of their race and ethnicity. Eligible families were identified from electronic health records across two endocrinology clinics in a multistate pediatric health system located along the East Coast of the United States. Purposive sampling was used to obtain diversity with regard to ethnicity, primary language, and diabetes technology use . Youth and caregivers were able to participate individually. Pediatric endocrinologists and advanced practice registered nurses who provided direct clinical care to youth with type 1 diabetes in these same two clinics were also eligible to participate. Eligible families and HCPs were recruited via e-mail with a message describing the purpose of the larger study. Research team members used text messages, phone calls, and e-mail messages to follow up with potential participants who did not respond. Research team members scheduled a study visit with families and HCPs who expressed interest in the study. At the start of the visit, families completed electronic informed consent and assent forms hosted in the REDCap online platform . To protect confidentiality, HCPs could waive providing their signature as documentation of consent. --- Data Collection Participants completed a demographics form followed by a semi-structured phone interview conducted by trained interviewers. Youth and caregivers from Spanish-speaking families were given the option to complete research procedures in Spanish or English; all caregivers completed interviews in Spanish, while all youth completed interviews in English. All interviews were audiorecorded and transcribed using a third-party transcription service. Youth and caregivers were paid $30 for completing the study. HCPs received a raffle entry for one of four $30 gift cards. --- Measures --- Demographics The demographic forms assessed race, ethnicity, age, and sex. Additionally, caregivers and youth reported on their education level and primary spoken language. EHR data provided youths' most recent A1C result, duration of type 1 diabetes, and insurance type . HCPs indicated their job title/role, years of providing type 1 diabetes clinical care, and whether they provided services in languages other than English. --- Interview Guides Three semi-structured interview guides were created . Interview guides were originally developed to assess families' perceptions of facilitators of and barriers to diabetes technology use. At the outset of the COVID-19 pandemic, questions were added to ask youth and caregivers who had a telehealth visit to share their perspectives on telehealth, whereas HCPs were asked how the pandemic affected their clinical care . Youth and caregiver interview guides were developed in English and then translated and certified in Spanish. Three bilingual stakeholders also reviewed the Spanish interview guides. --- Qualitative Analysis Spanish-language interviews were translated into English for coding purposes. All transcripts were reviewed for accuracy before coding. Qualitative analysis of all transcripts was conducted using Dedoose, 9.0.17 . Three members of the research team iteratively developed the codebook by examining transcripts line by line and identifying key words and phrases. All transcripts were coded by a two-person coding team . The coding team independently coded transcripts and met to review, discuss, and resolve coding inconsistencies and revise coding criteria . Another research team member experienced in qualitative research methods was consulted as needed to help resolve inconsistencies. A phenomenological approach was used to extract relevant themes regarding perceptions of telehealth for type 1 diabetes care during COVID-19. The coding team met multiple times to develop and revise the emerging themes using a constant comparative approach, comparing and contrasting exemplars within the data to formulate the final themes. --- Positionality Statement Reflexivity is the process through which researchers acknowledge and disclose how their own background and worldview influence their research . The racial and ethnic backgrounds of the authors are somewhat diverse and include non-Hispanic White , non-Hispanic Black/African American , and Hispanic White . All authors have graduate-level education in psychology, medicine, or public health. None of the authors have type 1 diabetes, but they do have experience providing clinical care or conducting research with youth with type 1 diabetes and their families. The authors with experience providing clinical care have used telehealth when working with youth with type 1 diabetes. The authors recognize that their professional and personal background may affect their approach to answering the research questions posed in this article, the information participants may have disclosed during interviews, and their interpretation of the findings. The research team worked to develop culturally sensitive research methods and had regular discussions to ensure that the study was guided by their cultural knowledge and expertise. --- Results --- --- Thematic Analysis Three major themes capturing participant perspectives on telehealth for pediatric type 1 diabetes care during COVID-19 were distilled from the data. They captured comments about 1) perceptions of telehealth, 2) feasibility of telehealth, and 3) quality of telehealth care. Details and illustrative quotes are provided below. Theme 1: Perceptions of Telehealth Seven youth and 10 caregivers had positive perceptions of telehealth. One caregiver liked the convenience of having telehealth appointments, saying, "Sometimes, when we are there [inperson], we were there for 2 or 3 hours . . . . She's here in the house. She does her lunch, and she can continue to have the appointment." One youth stated that attending telehealth appointments made him feel better. When asked to elaborate, he expressed how virtual appointments would "probably just [protect] the health of everybody who would have been there in person." A few caregivers and youth were initially unsure about telehealth, describing video calls as "strange," "different," or creating feelings of "anxiety." However, they tended to feel better about the experience afterward. Conversely, one youth and six caregivers had negative perceptions about telehealth. The one youth disliked the length of his appointment, stating that "it took longer than it would have taken in person." One caregiver felt that telehealth was not suitable for her child because "he's more of a type of patient that should be seennot somebody that should do a telehealth appointment." Another caregiver decided against attending telehealth appointments because, she said, "I didn't feel comfortable with doing [it] on the computer. We need to be able to talk to [the HCP] and not just [be] on the computer." In sum, despite some notable concerns, most families found telehealth to be an acceptable way to receive type 1 diabetes care. --- Theme 2: Feasibility of Telehealth Most families and HCPs discussed potential feasibility issues with delivering type 1 diabetes care through telehealth. Two Although one HCP noted that telehealth provided a more personal experience , most HCPs and caregivers raised concerns about the quality of telehealth diabetes care because of the lack of in-person interactions. One caregiver shared that she canceled her child's telehealth appointment and wanted to reschedule for an in-person visit. One HCP also expressed concerns about limited multidisciplinary care, saying, "A lot of our kids need good strong psychology support. I think they're doing a great job with telemedicine, but I don't think it's the same when you talk to someone on the phone versus in person." Most caregivers and HCPs also felt that the absence of physical examinations diminished the quality of diabetes care. One caregiver described telehealth as a professional experience, but said "the difference with [a] video call . . . is that . . . the doctor cannot do his physical examination . . . , which is the one that I think is important, especially for my child's condition." One HCP shared how physical exams shaped her perception of the quality of in-person versus telehealth visits, saying, "I think the care that I give when I'm doing a telemedicine visit is not as good as an in-person visit . . . because of not being able to examine the child . . . ." Some HCPs felt that the inability to retrieve type 1 diabetes-specific data made telehealth less effective. As described by one HCP , "I didn't have access to their meters to physically go through . . . . They did not have A1Cs necessarily for me to be able to gauge how things were going, so that definitely made it tougher to have an effective visit." However, a few HCPs believed that data from advanced diabetes technology devices improved the quality of diabetes care. One HCP described how device downloads informed clinical care more than A1C, saying, "We weren't able to do . . . a hemoglobin A1C, so that piece of information was missing when we saw them. But I don't think that it impacted the way in which we were able to provide care significantly because . . . most of them downloaded data and sent it to us or sent logs." In sum, many HCPs and families felt that care delivered via telehealth could be of lower quality; however, HCPs noted how advanced diabetes technology could help them deliver higher-quality care by telehealth. --- Discussion Our findings suggest that most families of youth of color with type 1 diabetes, in the context of COVID-19, had positive perceptions of telehealth, although a few families reported minor concerns. These findings are mainly congruent with prior research but extend the literature by identifying reasons why families of youth of color perceived telehealth positively . Importantly, our findings also point to reasons why families of youth of color may be uncertain about telehealth . These reasons for uncertainty are amenable to intervention, and addressing such issues may help to minimize disruptions in care. For example, it may be helpful to assess families' preferences for a mode of care delivery and level of comfort with telehealth technology before scheduling telehealth appointments to ensure that families receive care in their preferred way, when possible, and to identify families who would benefit from additional support to successfully complete telehealth visits. Interestingly, our data also suggest that some caregivers and HCPs in the sample felt that the absence of in-person contact and physical examinations diminished the quality of diabetes care, which is also consistent with previous research . Many aspects of the exam cannot be completed via telehealth , and the lack of in-person contact may hamper communication, which is essential to patient-provider relationships, treatment engagement, and satisfaction with care . Therefore, more research is needed to understand how physical examinations influence patient-provider relationships and to identify ways to promote patient-provider communication and relationships when care is delivered remotely. Relatedly, results from this study highlight the need for equitypromoting interventions and initiatives. Although telehealth enabled continuity of care during the height of COVID-19, previous research and this study suggest that telehealth could exacerbate disparities in health care access and delivery for families of color. Technical challenges were common, and digital literacy played a role, especially for non-Englishspeaking families. Furthermore, limited ability to share or access clinical data eroded participants' perceptions of the quality of care delivered through telehealth. Advanced diabetes technology devices such as CGM systems and insulin pumps could facilitate the sharing of clinical data for telehealth appointments ; however, there are persistent racial and ethnic disparities in the use of diabetes technology . To ensure that telehealth reduces disruptions in care for all youth with type 1 diabetes, clinics and health care systems need to identify and remedy factors and processes that contribute to disparities in care. --- Limitations The study's strengths include its use of rigorous qualitative methods, a stakeholder advisory board, inclusion of both family and HCP perspectives, and a focus on families from historically under-represented racial/ethnic groups. However, study findings should be interpreted with the following limitations in mind. First, the primary aim of the larger study was not to assess telehealth, which limited the number and types of questions participants answered. Only youth of color with type 1 diabetes were recruited given the aims of the larger study, thereby precluding the ability to compare themes across racial/ethnic groups. Future research should sample both White and non-White youth with type 1 diabetes to examine whether racial/ethnic differences in perceptions of telehealth visits exist. Additionally, the study had a low recruitment rate, as only 21% of contacted families were enrolled; however, this was sufficient to achieve saturation, and purposive sampling allowed for greater representation in this sample. Characteristics of the coding team could affect how the data were coded and analyzed; however, the team was racially and ethnically diverse and worked closely with the advisory board to protect against any implicit biases. The study was conducted early in the pandemic and used a cross-sectional design, which precludes the examination of changes in perspectives over FEATURE ARTICLE Telehealth and Type 1 Diabetes Care During COVID-19 time. Finally, the sample was well-educated, the study was limited to two endocrinology clinics within the same pediatric health system, and the HCPs sampled were limited in terms of racial/ethnic diversity, all of which are factors that may limit generalizability. --- Conclusion and Implications for Clinical Practice Most families of youth of color with type 1 diabetes had positive perceptions of telehealth during COVID-19, although some families and HCPs identified issues related to feasibility and quality of care. Understanding families' preferred modes for care delivery may help HCPs engage families of color in care . Health equity should also be proactively addressed to ensure equitable access to telehealth care. It is recommended that health care systems 1) examine whether disparities in telehealth access exist within their patient population, 2) develop ways to educate patients on how to navigate technology for telehealth visits, and 3) review structural processes to make appropriate technical and logistical changes to facilitate successful telehealth encounters . Results of this study also highlight limited access to clinical data as a gap in telehealth use. To mitigate this gap, HCPs should encourage more use of advanced diabetes technology among all youth, provide more opportunities for families to complete laboratory testing before telehealth appointments and assist as needed, and assess families' individual needs to optimize the quality of their telehealth diabetes care. ---

OBJECTIVE | At the outset of the coronavirus disease 2019 (COVID-19) pandemic, health care systems rapidly imple- mented telehealth services to maintain continuity of type 1 diabetes care. Youth of color are more likely to have suboptimal glycemic control and may benefit most from efforts to ensure continuity of care. However, research examining the perspectives of families of youth of color regarding telehealth for pediatric type 1 diabetes care is limited. We gathered perspectives from youth of color, their caregivers, and health care providers (HCPs) on telehealth for type 1 diabetes care during COVID-19. METHODS | Fifty participants (22 caregivers, 19 youth, and nine HCPs) completed semi-structured interviews conducted in English (n = 44) or Spanish (n = 6). Transcripts containing mentions of telehealth (n = 33) were included for qualitative analysis to extract themes pertaining to perceptions of type 1 diabetes care and telehealth use during COVID-19.| Themes related to perceptions, feasibility, and quality of telehealth diabetes care were obtained. Most families had positive perceptions of telehealth. Families and HCPs described logistical and technical challenges and noted the potential for disparities in telehealth access and use. Furthermore, caregivers and HCPs felt that the lack of in-person interaction and limited access to clinical data affected the quality of care. CONCLUSION | Families of youth of color with type 1 diabetes mostly had positive perceptions of telehealth but also iden- tified issues with feasibility and quality of care. Our findings highlight a need for interventions promoting equal access to telehealth and quality care for all youth with type 1 diabetes to minimize disruptions in care.

Each life stage comes with challenges and obstacles, and hence vulnerabilities and resilience may fluctuate across one's life span. Earlier analyses found that problem gambling risks generally decrease with advancing age , with youth problem gambling rates being two to three times higher than that of the adult population , particularly among males . However, increasing availability and exposure to gambling products and facilities, accompanied by notable rapid uptake of gambling by older adults , and marketing campaigns targeting older populations are challenging previous understanding of the relationship between problematic gambling and aging. Problem gambling has been defined as "difficulties limiting money and/or time spent on gambling which leads to adverse consequences for the gambler, others, or for the community" . This definition is chosen because it has been adopted as the national definition for problem The Gerontologist Cite journal as: The Gerontologist Vol. 54, No. 6, 103554, No. 6, -104854, No. 6, doi:10.1093/geront/gnt107 /geront/gnt107 Advance Access publication October 4, 2013 gambling in Australia and also because it encourages the viewing of gambling across a continuum, from nonproblematic levels to the most severe forms. It is well documented that problem gambling prevalence is significantly associated with gambling availability, accessibility, and participation, particularly of electronic gaming machines . These machines are the equivalent of the North American slot machines, although the review of Australia's Gaming Industries by Productivity Commission note that the former differ to some extent from some of the latter in being rated as higher intensity machines in terms of speed of play and number of lines and credits that may be played in a single "spin." EGMs, or poker machines, are colloquially known in Australia as "pokies." In Victoria, where the current study was undertaken, these machines became legalized in 1992 and today are located in over 560 community-based venues such as clubs and hotels and in the state's casino , making up a population ratio of 6.1 EGMs per 1,000 adults in the state. Increase in gambling opportunity and older adults' enthusiasm toward EGMs have therefore sparked concerns that these trends may culminate in late-life gambling problems. In particular, due to the unique life experiences in late adulthood and vulnerabilities , late-onset problem gambling consequences may be more devastating than for younger adults. The damage done may be irreversible and even life threatening, as reflected in elevated suicide and suicidality rates among problem and pathological gamblers . Although gambling is a rather popular activity in later life, late-life problem gambling is considerably hidden. In Victoria, Australia, approximately 73% of adults have been shown to gamble in any one year, with their games of choice being, in decreasing order, lotto/Powerball/Pools, raffles/sweeps/competitions, EGMs, horse/harness/ greyhound racing, and scratch tickets . Those aged between 50 and 64 years were more likely to participate in EGMs, lotto/Powerball/Pools, and competitions than the rest of the population; whereas those aged 65 and older were likely to favor bingo more than other Victorian adults. Although in North America, from where the majority of the evidence on seniors and gambling originates, the prevalence of problem gambling in older adults can span from approximately 2% to as high as 17% depending on the region and scale of survey , whereas in Australia, statewide surveys tend to yield a lower rate of senior problem gambling prevalence. Specifically, in Victoria, the 50-64 years cohort had the second highest prevalence of problem gambling , and for adults aged 65 and older, problem gambling was more prevalent in women than in men . It therefore appears that the trend of males being more at risk of problem gambling is reversed in older age, at least for this cohort. Late-onset problem gambling has characteristics that are distinguishable from lifetime or earlier onset problem gambling. For instance, Petry found that, contrary to lifetime problem gambling, late-life problem gambling was more associated with women and increased employment problems than social, legal, and substance-abuse problems. The older women reportedly took up gambling at the average age of 42, and regular gambling did not commence until the average age of 55 years. Similarly, Grant, Kim, Odlaug, Buchanan, and Potenza found that the late-onset group was neither likely to declare bankruptcy and have credit card debt attributable to gambling nor likely to have a parent with a gambling problem but were significantly more likely to suffer from anxiety issues. These differences suggest that generic risk factors and correlates commonly found in the general adult population may not necessarily apply to late-life problem gamblers , which warrants further investigation. The authors of the present study previously attempted to fill in this knowledge gap by conducting a thematic analysis and domain categorization of extant senior-specific literature and cross-matching emerging patterns with the generic pathways model of problem gambling . This model, which provided the conceptual framework for the present study, suggests that problem gamblers are a heterogenous population with three major pathways leading to problem status: Pathway 1-the availability of gambling activities and psychological conditioning lead to a pattern of habitual gambling and chasing losses, which results in problem gambling; Pathway 2-builds on the trajectory of Pathway1 but incorporates emotional vulnerability . This cohort has a history of significant negative life events coupled with poor coping and problem-solving skills, and accordingly gambles primarily to address negative affect; Pathway 3incorporates biological vulnerability and impulsivity traits such as ADHD and antisocial behavior and represents the most severe form of problematic gambling. Our previous study generated three main clusters: concerning individual vulnerability factors, concerning social and environmental factors, and concerning behavioral regulation. These results represent one way of grouping the findings and may be limited by the inherent methodological limitations associated with some of the studies analyzed, as well as the dominance of the North American context of the research reviewed . Consequently, it is unclear to what extent these findings could be generalized to the Australian context, where the milieu of gambling is comparably more diverse and characterized by high rates of dispersed , as distinct from centralized gambling opportunity . In contrast to this prior analytic approach, the current study utilized a ground-up perspective for addressing senior-specific problem gambling pathways. Specifically, it directly engaged Australian older gamblers and traced conditions that were subjectively perceived as causing vulnerability toward harmful gambling. The purpose of the study was to develop a grounded theory through semistructured in-depth interviews on how older adults, who may not have previously experienced gambling issues, come to develop gambling problems in later life. --- Design and Methods --- Analytic Approach and Participants As the aim of the study was to build a theory on pathways into late-life problem gambling, the grounded theory approach was considered appropriate. The conceptualization procedures therefore involved coding, categorizing, memoing, constant comparison, and theoretical sampling. Specifically, applying a constructivist grounded theory methodology meant that emphasis was placed on the identification of pertinent constructs, the associated properties, and supporting codes. Concepts of similar characteristics were grouped together under a common classification or category, and the accumulated interrelations were subsequently integrated to form the core of the emerging theory. As not all categories were equally relevant, the depth of inquiry into each category varied. Focus was therefore directed at reaching saturation with regard to core themes as much as possible, for these serve as categories that would hold the most explanatory power . Thus, categories that appeared to be less relevant for predicting and explaining the later life gambling behaviors were gradually eliminated. To address the trustworthiness of the data interpretation, a random sample of transcripts were reviewed by the two authors , who had not collected the data and undertaken the first thematic analysis. No areas of disagreement emerged. The participants were respondents from newspaper advertisements, project flyer distributions, snowballing, and a problem gambling counseling service newsletter. The sample inclusion criteria were older adults who were aged 55 and older, who were either regular gamblers or have ever experienced later life gambling issues , and who were able to understand and consent to the research project. Exclusion criteria involved younger adults, presence of health conditions that might hinder participation in an hour-long interview, and the inability to provide a free and informed consent. As a token of appreciation for their time, participants were offered a $20 department store gift card at the end of each interview. In order to identify pertinent risk factors and catalysts without having to intrude excessively into life histories, attention was focused on key life events and turning points that coincided with gambling onset and/or transition from regular gambling to problematic gambling. As key themes surfaced, the interviews progressively increased in structure and focus. Because both problem and nonproblem gamblers were recruited, both risk and protective correlates were gathered. Nonetheless, as this study focuses on the problem gambling pathways, the current findings were primarily informed by participants with a problem gambling history, although data from the rest of the sample helped suggest pathway interruptions and exits. Even though saturation occurred approximately after the twentieth participant was recruited, the researcher continued to recruit up to 30 participants in order to check the scope of the emerging theory. The additional one was due to a participant e-mailing her story over in the midst of recruitment. --- Results --- Sample Demographics Thirty-one older adults aged 56-85 participated in the study. The average age was 67. Although 30 of the participants were interviewed face-toface, a supplementary story was e-mailed to the researcher by a participant who preferred to not meet personally but was nonetheless comfortable with sharing her gambling experiences. Of the 31 participants, the majority was female, with nine males: 8 were married, 16 were divorced or separated, 5 were widowed, and 2 never married. Six participants were employed full time or part time, and 25 were retired. In terms of income source, 25 were receiving pensions and 6 were selffunded retirees or employed. Fifteen participants described their ethnicity as Australian: three each as Yugoslavian, Greek, or Turkish; two each as Italian or English; and one each as Dutch, Finnish, or British. Apart from three participants who were from three different country regions of Victoria, the rest were recruited from metropolitan regions. --- Sample Gambling Situations Overall, six participants described themselves as currently having gambling problems for which they were not seeking treatment, eight reported having sought self-exclusion from gaming venues and perceived themselves as "recovering" or gaining more control over their gambling behaviors, and four reported a history of binge gambling due to previous intermittent experiences of gambling issues. Conversely, nine presented as regular nonproblem gamblers . Two considered themselves "professional" gamblers , and one presented as a self-recovered late-onset problem gambler whose gambling was regarded as currently under control. --- Key Themes The fundamental social process involved in rendering the participants vulnerable to problem gambling was found to be the process of becoming "isolated," which could be both the cause/precipitating factor, as well as the by-product of gambling problems. The concept of "isolation" consisted of properties such as having "nobody there for you," "nobody for you to be there for," "nothing much else to look forward to," and "gambling venues as places for the isolated to unite and belong." Findings also suggested that as problem gambling risks escalated, participants displayed a tendency to consider gaming machines as their "companions," which in turn increased their "isolation" and dependence on gambling venues/products to achieve a sense of belonging and/or "companionship." Moreover, for a considerable proportion of the participants who experienced gambling problems, gambling appeared to be used to replace work, which reportedly was the antidote to all of life's stresses during their employment years. Consequently, the concept of "isolation" also included properties such as "gaming machines as the isolated's companions," "work as previous distraction," and "gambling products enhanced the feeling of being isolated." The construction of "isolation" is summarized in Table 1. The number of times each code was reflected in the interviews is indicated in brackets after each code name, indicating the relative density or salience of each code. These densities or support for each component were used to guide the development of the grounded theory through examination of their occurrence and the inter-relationship of the codes within each construct. The first property-"nobody there for you"could refer to both a representation of an idea, as well as an actual or literal situation. Specifically, the more tangible or concrete aspects of this property were found to encompass conditions such as loneliness, scarce social contact/difficulties in meeting and forming new friendships, lack of support, and relationship conflicts. The more hypothetical or abstract aspects entailed superficial existence, having to live behind a mask, and fear of dying alone. In particular, part of what made gambling venues a favorite place for lonely participants to spend time was reported because they could go there on their own, do something on their own, and still be able to enjoy themselves. All names are pseudonyms. It's one place you can go . . . where you can go in on your own, and you don't have to be with someone. That's a very big factor. Because I would not walk into a pub on my own . . . and sit and have a drink . . . but you can walk into a venue . . . if you're lonely and . . . and you don't have to drink, you just have to play. The above example portrays "isolation" as a lack, specifically of human contact. In contrast, for another participant, "loneliness" was more covert and complex in nature, and "isolation" was a mix of various losses, severe grief, inability to truly be oneself among one's network, and a sense of a bleak future. "We always say we . . . we put in full time . . . between us, over 80 years into the workplace . . . and we saved, and we . . . we bought this house . . . and we've . . . we've . . . uh, had some money for our retirement, and our retirement was going to be full of wonderful things . . . But his illness . . . um, has . . . stopped that . . . I'll be 70 in a couple of years . . . and . . . um . . . I see, um . . . ahead of me, it's . . . only in a short span of time . . . that I may . . . be active enough, uh, in health terms . . . For another participant, "loneliness" meant living behind a mask. It's always been known that . . . comedians . . . are the loneliest people on earth. And it is quite true, Closely related to the property of having "nobody there for you" was having "nobody for you to be there for," which covered aspects such as the need to be needed, the need to control, and a sense of redundancy. Some participants were rendered "isolated" when they were made to feel unneeded or unwanted for various reasons, such as through lack of responsibilities, lack of respect and recognition, discrimination, and technological advancements. The impact of feelings of redundancy appeared to be greater for competitive individuals, who simultaneously seemed to have a considerably harder time accepting negative gambling outcomes. This consequently led to the development of obsessions about winning strategies, and the subsequent acceleration down the "isolated" path more rapidly than their noncompetitive counterparts. On the other hand, a personality trait that was found to be commonly shared between the participants in the sample was being young at heart. As a consequence of having this trait, many of the participants reported that they did not really fit in with the mainstream older population and could not really derive much entertainment or satisfaction from existing services that cater to seniors. In particular, existing senior citizen's social clubs and their associated activities were found to be dull and uninteresting. Accordingly, this often prompted a need to seek out the company of other young-atheart older adults, who were perceived as often found at gambling venues. In fact, joining seniors' clubs even diminished some of the participants' sense of well-being. I don't like them [seniors' social clubs] because, um . . . they all look very old and, um . . . you go there and . . . you feel like you're . . . ready to jump in the grave! All these people, you know, they're all very old and . . . and they look old and, um . . . um . . . they dress old and, um . . . and not, um, modern . . . and not having good clothes to wear or anything and they look . . . like beggars, you know? You think: Oh, why did I come here? I used to go to a [cultural] . . . club down there . . . it's a disaster. You only have to do jobs down there. You have to make coffee for them and . . . 'Oh, this coffee's no good, there's not much sugar', uh, 'It's too strong', 'It's too weak', you know, they're all complaints that's all, so I don't go there anymore. Not happy . . . going to those places. Thus, existing senior-specific social clubs may not be suitable for all types of seniors, particularly those like some of the study participants who were disengaged from mainstream services. It was not uncommon for participants in the sample to report meeting like-minded people, and/or people who were going through similar things in life, at gambling venues. Consequently, gambling venues became a setting that enabled vulnerable individuals to meet one another, share with one another, confide in one another, and for those who did not really interact with others, at least provided them with a sense of belonging. Older people that are lonely and . . . are lost and . . . they don't fit into something in this world, so . . . we go to the pokies and . . . enjoy one another's company. There's not a lot of places to go . . . with people. And . . . because . . . these day and age, people aren't really friendly anymore . . . very hard to . . . to meet people and share with people. Nonetheless, although a considerable proportion of the participants reported gambling due to loneliness or to meet people, this ideal was often not realized, with participants also reporting, paradoxically, wanting to be left alone to interact with the machines. And the machine's your partner [chuckles] The machine becomes your partner. Well . . . you tend to talk to it. Um . . . Oh, a lot of people do. It's not just me. A lot of people do. [Demonstrates stroking an imaginary EGM]: Um . . . "It's my turn," you know, "Come on, be good" and . . . "Be lucky for me tonight" and . . . yeah . . . all that sort of . . . thing. When asked why, despite feeling lonely, he would rather have EGMs for companions instead of people, another participant's reply was At least you won't get an argument out of the machines there. Hence, it appeared that for some, social conflicts were considered more stressful than gamblingrelated losses. Conversely, as participants frequently talked about using gambling to cope with one thing or another, enquiries were made into previous coping strategies that were applied before EGMs were adopted. For an overwhelming majority of those with current or previous gambling problems, the concept of "free time" never really existed prior to their EGM uptake, and/or work was their "hobby." Nevertheless, for some, previous coping strategies involved nicotine and/or alcohol consumption, which in the current sample appeared to be male specific. These findings suggest that overt coping mechanisms of "the isolated" may include substance use/abuse, whereas more covert coping mechanisms may involve workaholism. However, because most participants were brought up with rather strict work ethics, workaholism was rather hard to diagnose and was beyond the scope of the current study. Findings also indicated that some individuals had higher sensitivity toward stimulation than the rest of the sample. Indeed, it appeared that for these participants, perceived EGM-related effects on their mind were immediate as opposed to a gradual development, and the impressions of machine features were not just transient images, but rather, they repeatedly replayed in their minds, and EGM-related sounds continued to ring in their ears long after their gambling sessions. The colors, noise, vibrancy and features of the games on the screens stayed in my brain like imprints, and seduced and lured me back and back again, hundreds of times. That's the planning behind the seductive images. Much study of human psychology must go into the design of the programs. And then you have-you go to bed . . . and the machine's still going off in your head, and you can't sleep. So you get up and go to work the next day and you've had no sleep, and you've got no money and you're stressed and you. . . . and I've been doing that for the last ten years. The quotations above demonstrate that the "experiences" that vulnerable gamblers go through while gambling may differ from those who are less vulnerable, specifically in the way the former group's gambling experiences were often "all-consuming," which did not appear to be the case for the latter group. The following three pathways-grief, habit, and dormant, respectively -represent trajectories that rendered the current sample "isolated" or vulnerable to latelife problem gambling. The discussion of each pathway covers entry, progression, and maintenance or perpetuation of the trajectory, based on analysis of the interviews. Exiting pathways is covered in the discussion section. The key components of the pathways are summarized in Tables 234. --- The Grief Pathway Pathway Entry: Substantial Losses.-Gamblingrelated vulnerabilities associated with this pathway essentially involved losses of various forms and magnitude, such as an illness striking a loved one or oneself, an anger-provoking event, stress and anxiety associated with conflicts, presence of abusive/manipulative/negligent relationships, and/or what some participants had summed up as "a hard life." The gambling triggers were often situation specific-as opposed to being related to a presumptive biological or genetic predisposition-and these were reflected in participant history, where something subjectively stressful reportedly preceded or occurred around the time of regular gambling initiation, which prompted the need to seek out gambling and/or gamblingrelated venues/incentives, whereas prior to such turning points, these individuals reportedly functioned well. Such presentation patterns suggest that the main catalysts for problem gambling progression in this pathway are potent negative emotions-which in the current sample included chronic loneliness, despair, depression, panic, desperation, and rage-which may be activated by certain thoughts, memories, reminders of various forms, or as a consequence of certain realizations finally sinking in. Pathway Progression: Mismanagement or Non management of Losses.-Due to the sheer force of negative emotions associated with this pathway, participants experiencing this pathway primarily gambled to avoid feeling emotionally overwhelmed or to have a break from emotional exhaustion. This pathway is therefore predominantly underpinned by the presence of unresolved issue, which in the current sample appeared to be exacerbated by the lack of opportunities for grieving, be it due to selfimposed standards, social expectations, or an overload of responsibilities. Because the triggers for this pathway primarily involved affect or mood states, and rarely had anything to do with gambling per se, gambling outcomes were often found to be of little if any significance to the respondents, and winnings were frequently of minimal import or their value was short lived. This was evident in the way the participants talked about the emptiness of gambling, the meaninglessness of wins, and how when asked what their gambling involvement meant for them, the answers were often given as "nothing really." Pathway Perpetuation: Gamble to Forget and/ or Augment Personal Space.-Participants on this pathway characteristically only gambled when feeling upset or needing time alone. Thus, the need to gamble was usually dispelled when these participants were coping/content with life, or the reminders of their distress were absent. Accordingly, motivation to continue or increase gambling was largely associated with the drive to disregard reality and ease emotional pain. Compared with the other pathways, participants experiencing this pathway appeared to most likely to prefer the "company" of EGMs than actual human interactions. Consequently, gamblingrelated wins appeared to neither significantly spur these participants on to gamble more nor did gambling-related losses appear to deter them from further gambling. Nonetheless, for those who were considerably enlivened after gambling-related wins, who attached sentimental meaning to gambling , who came to rely on venue-related services and incentives to feel better about themselves , or who subscribed to the construct of "nothing much else to look forward to," complications often followed due to additional layers of emotional needs. This means that a cycle of needs that begets more needs, or the formation of secondary needs on top of unmet primary needs, may occur, and this can further complicate the trajectories of this pathway. --- The Habit Pathway Pathway Entry: Subjectively Minor Unmet Needs.-In contrast to the grief pathway, participants experiencing this trajectory reportedly enjoyed "a good life" prior to experiencing gambling problems, in the sense of lacking anything to complain about and any major unresolved distress, anxiety, or melancholy. Consequently, this pathway was marked by relatively minor and rather straightforward needs for an "out" that were met by gambling, thereby suggesting that their degree of being "isolated" appeared to be relatively mild. These minor needs included missing the kind of responsibilities that one used to enjoy , missing the times when one was needed , running out of things to do to occupy one's time , the desire to stir up routines , and/or the desire to merely try out something different and exciting . Conversely, for others, the initial triggers manifested as a need for a change of environment and gambling venues happened to be the closest location; a need for a place to spend time outside of one's residence and gambling venues were found to be safe and consistently open; a desire to postpone one's return to an empty house and gambling venues turned out to be the only locations that opened till late; or in rarer cases, a desire to prolong fun and happy feelings after a great day at work and gambling was perceived as enabling the momentum of positive feelings to continue. Pathway Progression: Winnings/Luck Encouraged Further Gambling.-Regardless of what the initial motives may have been, the main catalysts for gambling progression or escalation in this pathway were found to be centered around big wins/beginner's luck or "lucky feelings," which fostered subsequent need to chase bigger wins/losses, or to allow opportunities for lucky feelings to translate into actual wins. Consequently, unlike participants from the previous pathway, participants on this pathway were rather motivated to win at gambling and gambling outcomes mattered considerably. Thus, this group appeared to be mainly after the stimulating effects of gambling and was more likely to stop gambling if early gambling experiences were negative. Pathway Perpetuation: Gambling Out of Habit.-It was not uncommon for participants on this pathway to concur that although they started off gambling out of boredom or to be out of the house, these eventually became an "excuse" to gamble further. This is because they reportedly became so accustomed to frequenting gambling venues whenever they had the time and money, that when other engagements or opportunities for engagements arose , they still preferred to gamble instead. Thus, the main perpetuating factor for this pathway appeared to be the formation of a gambling habit that overrode other activities, and which was intensified and complicated by the desire to chase losses and bigger wins. This means that with regard to the construct of "isolation," participants on this pathway mainly endorsed only a few and rather scattered components of each aspect of the construct. Nonetheless, if complications were to occur, such as depression secondary to gambling problems, then more components of "isolation" are likely to be endorsed. --- The Dormant Pathway Pathway Entry: Existence of Comorbidities.-Participants experiencing this pathway appeared to have preexisting predispositions toward compulsive behaviors. For instance, in the current sample, there was a participant with Tourette's Syndrome, whereas others described themselves as having an "addictive personality," an "obsessive-compulsive outlook on life," or possessing an "addictive gene" due to a family history of heavy gambling and/or alcohol consumption. Nonetheless, due to lack of prior opportunities to gamble or gamble regularly, these vulnerabilities only manifested themselves in problematic gambling in later life. Although participants on the previous pathways were inclined to describe their gambling progression as insidious, participants under the dormant pathway were more likely to express their gambling as an "instant attraction" or "instant hook." In fact, a rather distinct gambling-related behavior associated with this pathway was that these participants often placed larger bets and did not appear to be satisfied with small bets , thereby reflecting an arguably stronger tendency to take more risks for the enjoyment of taking risks and/ or a comparatively lower level of self-control. These participants also demonstrated a lack of coping skills or poor coping strategies in the past, such as relying principally on nicotine and/or alcohol to relax and unwind , sleeping their days away to kill time, or engaging in compulsive eating whenever bored. Overall, it appears that participants on this pathway presented with relatively more indications of vulnerability in their psychosocial history than the rest of the sample. --- Pathway Progression: Gambling Behaviors Propelled by Comorbidities.-Unlike the previous pathways, the dormant pathway did not appear to require any specific triggers or external encouragements for gambling urges to be elicited, although it could be aggravated by these factors. This is because this pathway entailed the presence of comorbidities, and in particular, a history of other forms of addictive behavior. Such precarious foundations, or somewhat "dormant" vulnerabilities, once triggered appeared to create a momentum of its own so that gambling progression appeared to occur more rapidly than the previous two pathways. Consequently, these participants were generally more likely than the rest of the sample to endorse gambling problems as "feeling addicted," as well as being the second group to most endorse the construct of "gambling venues as places for the isolated to unite and belong." Thus, in terms of "isolation," it would appear that these participants were isolated because other forms of outlets could not seem to help ease tension and offer satisfaction, which may have contributed to their perception that gambling venues offered a sense of shared purpose or community. Pathway Perpetuation: Avoidance of Gambling Related Withdrawals.-At the core of their gambling motivations, participants on this pathway appeared to experience "genuine" gambling urges, in the sense of having gambling itself as the main goal/ reward and less emphasis on the secondary benefits of gambling, such as to regulate emotions or chase bigger wins/losses. As such, physical withdrawal symptoms associated with gambling cessation or reduction, such as shaking or trembling hands, which were not reported under the other pathways, were found under this pathway. Consequently, gambling motivations associated with this pathway appeared to be characteristically associated with the need to satisfy gambling-related urges to calm the mind from incessant thoughts about gambling and to avoid/ease withdrawal symptoms. --- Discussion A number of pathways-grief, habit, and dormant-have been identified in this study, all three of which rendered the current sample isolated or vulnerable to late-life problem gambling. These pathways to some extent reinforce the heterogeneity proposed by Blaszczynski and Nower and the pathways in their model, and reinforce some of the clusters identified and previously proposed by the present authors. Because findings are based on participants' interpretation of their lives and their gambling-related experiences and the meaning that they attached to these, the construction of isolation fundamentally represents the symbolic interaction between the participants and their environments . Nonetheless, this does not negate the importance of macrosystemic factors that can considerably influence the trajectory of problem gambling development and progression. Because findings suggest that isolation and sense of redundancy can significantly propel vulnerable individuals to seek destructive ways of boosting self-esteem and regaining meaning/ purpose in life, late-life problem gambling prevention entails the promotion of environments that are socially inclusive and a society that does not judge or devalue people because of inevitable factors such as age. Rather it should appreciate past contributions while provide ample opportunities for further contributions. Examples of interventions, some of which were nominated by interviewees, include the following. Policy makers can help by subsidizing or offering free courses to retirees so that older adults-especially those who have spent most of their lives working and hence struggle to deal with the extra free time upon retirement-can develop new interests and hobbies and learn about alternative ways of meeting emotional and social needs. In addition, abundant opportunities for positive involvement, for example, through the creation of mentoring programs where older adults are linked with teenagers/younger adults, thereby allowing retirees to continue to feel useful and valued by society while preventing isolation could be provided. Senior-friendly neighborhoods could be promoted, whereby adequate recreational options and social venues are provided within local settings, so that older adults can feel safe to venture out and socialize and not have to rely solely on gambling venues as their only secure, communal, and easily accessible destinations. Policy makers should continue to listen to older adults and understand the changing contexts of aging so that policy initiatives are always relevant to seniors' needs, and resources channeled into aging sectors and programs are most efficiently applied. As gambling was found to be used to replace work and its distracting effects, this has significant implications for education around alternative leisure options and emotional outlets. For instance, activity scheduling interventions that help associate positive mood with nongambling social activities and mood monitoring in the context of daily activities can be helpful for both treatment and prevention strategies. In addition, as several participants were found to have an inclination toward dismissing losses and/or minimizing the impact of losses, so as to "just get on with it" as soon as possible, part of retirement planning should therefore include raising awareness about the processes of grief, reminding older adults that some forms of grief may take longer than others to heal and assuring older adults that just because they may take longer than someone else they know to grieve or get over a similar kind of loss, it does not mean that they are "weaker" than that person. Indeed, the emotional and social aspects of retirement may be the hardest part of retirement planning and may also represent aspects most easily overlooked by retiring individuals because income, assets, and finances tend to be at the forefront of retirement planning strategies . Accordingly, empowering interventions that help equip older adults with copious ideas on how to compensate for losses are vital. Due to the predominantly emotional nature of the underlying causes for late-life problem gambling, it may be more effective for intervention strategies to appeal more to sentiments than to rely chiefly on altering cognitions. Indeed, the late-life problem gamblers in the current sample were generally aware that the odds of winning at gambling were against them, but the majority appeared to be too overwhelmed by strong emotions to be able to harness any previous productive coping mechanisms, and some appeared to be too lost in gambling-related fantasies to be able to regain insight on their situations. Thus, the main issue was not ignorance of gambling odds, but rather emotional struggles. Accordingly, repetitive reinforcement of the probabilities of wins and losses at gambling are unlikely to be effective. In fact, there is growing evidence to suggest that older and younger adults process, interpret, and respond differently to risk messages and that emotions may assist with information integration in late life . Thus, a homogenous way of educating the public about problem gambling-related risks may be ineffectual, and this needs to be taken into consideration when designing interventions. --- Interventions to Assist in Terminating Pathway Trajectories The intricate emotional needs associated with the grief pathway suggest that effective interruptions to this pathway entail availability and accessibility of emotional support, opportunities for alternative outlets, and substituted forms of respite. Treatmentwise, cognitive behavioral therapy may help to replace triggering thoughts, alter unhelpful belief systems, and minimize the inclination to link and develop somewhat unrelated hopes and dreams to gambling-related activities. Nevertheless, if affected individuals were to become aware of their own triggering thoughts and underlying needs and come to resolve or let go of the losses experienced, selfrecovery may be possible. Because the habit pathway was predominantly underpinned by relatively more straightforward vulnerability factors, it would appear that unlearning somewhat conditioned responses to boredom and idle time is likely to be adequate while gambling habits could be replaced by alternative habits instead . Interestingly, there were instances where the novelty of gambling actually wore off and the participants decided to progressively gamble less on their own due to an increasing sense of tedium with EGMs. In fact, a few participants reported that what used to appeal to them now annoyed them instead, such as gambling venue-related noises and lights. This suggests that individuals in this problem gambling pathway may more readily experience "natural recovery," or have a higher chance of doing so, than those who develop problem gambling via the other pathways. Due to an almost "pure" quality of gambling urges that underpinned the dormant pathway, in the sense of gambling predominantly for the sake of gambling itself, this group of participants appeared to likely benefit from strategies such as playing gambling-simulation computer games instead of real EGMs. In this way, gambling urges could be fulfilled without real money being lost. Nevertheless, where actual monetary rewards are deemed paramount, where there is a need for gambling atmosphere, the need to be out of the house, or where emotional complications such as grief, loneliness , or depression are present, this strategy is unlikely to be effective. Moreover, due to existence of comorbidities, these "background" conditions are likely to require addressing so as to not hinder gambling improvement and/or accelerate pathway progression. Thus, potential terminations of this pathway would depend on a variety of factors, such as the nature of underlying gambling motivations and the types of comorbidities involved. --- Strengths and Limitations Because attribution of a "problem gambling" status was left to participant discretion, a range of gambling experiences was encountered, which enabled differences between nonproblematic recreational and problem gambling to be explored. Although issues such as denial and false claims may be common in the field of problem gambling , the "how's" of meaning making are just as important as the "what's" of meanings produced . The researchers therefore argue that any presence of inconsistencies between selfreported claims and presenting facts actually adds to the richness and complexity of the findings rather than compromise them. Moreover, because both problem gamblers and regular but nonproblem gamblers were included in the study, this allowed for factors identified as mediating, moderating, and/or interrupting pathway progression to be extracted, which adds to the uniqueness of the derived theory. The proposed grounded theory on pathways to late-life problem gambling was developed in a manner that was able to fit the data gathered. As such, the theoretical propositions and pathways posited are likely to be most transferable to populations of similar presentations, such as late gambling uptake and late-onset problem gambling among EGM players of mostly Anglo-Saxon background, who reside in an area where gambling contexts are similar to Australia . Nonetheless, the proposed theory is flexible and should not be applied as a principle or fixed guideline. Instead, the current propositions should help spark considerations for how societies and future social contexts may inadvertently create isolation and help promote ideas for how these can be prevented and minimized. In this way, vulnerable individuals can be protected from gambling-related adverse impacts before empirical evidence on further pathways can be established or become available. The researchers therefore encourage creative application and transfer of the proposed knowledge in ways that can help capitalize on the usefulness of the current findings and enhance openness to how other extant knowledge in the field can be applied. It should be noted that higher code densities are not synonymous with greater significance or influence. Care should therefore be taken to not assume that a construct with greater code density is a more important construct, as salience does not mean impactful. One should also be aware that neither the pathways that vulnerable individuals undergo may be as "neat" as presented in this study nor do individuals always remain in the same pathway or develop gambling problems from a single pathway. Indeed, pathway crossovers are possible, and the components of each pathway are fluid. Hence, lack of substantial endorsements of constructs or its components does not necessarily mean less problem gambling risks are involved. --- Conclusion Three main pathways to late-life problematic gambling have been identified, all linked with a common theme of isolation: a grief pathway associated with unresolved losses; a habit pathway associated with habituation to gambling; and a dormant pathway marked by preexisting behavioral excess or impulsivity. It is important to note that overall, unresolved losses and/or mismanagement of life's stresses were found to be the most significant predictors of late-life problematic gambling. In order to explore this further, rather than trying to find other categories and constructs that may be endorsed by a problem gambling sample, future research might benefit more from obtaining the various combinations of potent relationships of constructs, their subcomponents, and their interrelated properties so that the most potentially damaging problem gambling pathways could first be interrupted. Because a grounded theory is developed from the data itself, it can neither be destroyed by more evidence nor be deemed "right" or "wrong." Rather more evidence would serve to modify it into an improved theory . Hence, future studies of a similar topic will contribute to this foundation, enriching it, and extending the scope of its application, and any subsequent divergence from the proposed theory and hypothesized pathways merely represent a more updated version of the current theory, reflecting the dynamic nature of theoretical development.

To develop a grounded theory on how older adults, who may not have previously experienced gambling issues, come to develop gambling problems in later life. Design and Methods: Through semistructured in-depth interviews with 31 adults aged 56-85, routes that led the current sample of older adults to develop late-life gambling problems were identified and mapped into coherent pathways using a constructivist grounded theory methodology. Results: Three main pathways to late-life problematic gambling were identified, all linked with a common theme of isolation: a grief pathway associated with unresolved losses; a habit pathway associated with habituation to gambling; and a dormant pathway marked by preexisting behavioral excess or impulsivity. Overall, unresolved losses and/or mismanagement of life's stresses were found to be the most significant predictors of late-life problematic gambling. Implications: As late-life problem gambling appears to predominantly signify late-life emotional distress and an attempt to deal with this distress using gambling as an escape, it is crucial for problem gambling prevention programs to raise awareness about the processes of loss and grief and provide ideas about constructive loss management. In addition, community-level recreational and social opportunities to combat isolation are identified.

Introduction Understanding the bias in self-reported health and its determinants is of utmost importance, because subjective data are often the only information at hand when researchers and policymakers ask health-related questions. These data are readily available as their collection takes less time and is more cost-effective than performance-based health measures. However, several studies show discrepancies between tested and self-reported health indicators [1][2][3][4][5][6][7][8][9]. In a metaanalysis, [1] find that correlation coefficients of tested and self-reported functional ability range from -0.72 to 0.60. Thus, subjective health measures are prone to bias. Assuming an underlying true but unobservable health status, survey respondents will report a higher or lower level of health depending on their demographic characteristics. Over-and underestimating health does not only harm the reliability of survey data, but also individuals themselves. The remainder of this paper is structured as follows. The dataset is introduced in Section 2 with a description of both the self-reported and performance-based variables utilised. Next, the methods used are explained in Section 3. Sections 4 and 5 present our results, which are discussed and compared with previous work in Section 6. Additional estimations along with robustness analyses are provided in S1 Appendix. --- Data and variables The data analysed are provided by SHARE, a cross-country panel study of non-institutionalised individuals aged 50 and older who regularly live in one of the participating European countries [21][22][23][24][25]. The survey was launched in 2004/2005 in 11 European countries with more countries joining in the follow-up waves, resulting in 18 countries participating in 2015 in Wave 6. SHARE was reviewed and approved by the Ethics Committee of the University of Mannheim and the Ethics Council of the Max Planck Society [26]. For our analysis, we require pairs of tested and self-assessed health measures that can be matched directly. SHARE provides two such pairs, namely for mobility and cognition. Since the performance-based test for mobility is conducted in Wave 2 and Wave 5 only, we pool these waves to analyse self-reports of physical health [27,28]. Wave 4 ) and Wave 5 provide suitable data for the analysis of self-assessed cognitive health [29]. In summary, the analysis is based on pooled cross-sectional data with 88,087 observations from 17 different countries for mobility and 115,785 observations from 17 different countries for cognition. --- Outcome variables We investigate the reporting behaviour in two health dimensions, mobility and cognition, by comparing the results of a performance test and its adequate self-report. The self-reports are requested prior to the respective performance test for mobility and cognition, and thus the test results do not influence the subjective health measures. We assume that the performance test and its self-report cover the same health dimension. Therefore, we are able to assess whether the two variables coincide, after dichotomising them where necessary . Consequently, three different combinations of objective and subjective health measures are possible for each survey participant in the study. First, respondents achieve concordance if they have the same outcome in both the performancetested and self-reported variable. Importantly, we do not distinguish between positive agreements and negative agreement . Second, respondents are considered to be overestimating their health if they report no impairment but are actually impaired according to the performance test. Third, respondents are considered to be underestimating their health if they report impairments but show no impairment during the performance test. Mobility indicators. Performance-based mobility is measured by a chair stand test conducted in Waves 2 and 5. While all individuals were asked to perform a chair stand test in Wave 5, only individuals aged 75 years or younger were asked to do this test within Wave 2. Because Greece, Ireland, and Poland only participated in Wave 2, concordance of mobility measures can only be observed for the population aged 50-75 in these three countries. For the mobility performance task, survey participants were asked to stand up from a chair without using their arms. Specifically, the interviewer gave the instruction, "I would like you to fold your arms across your chest and sit so that your feet are on the floor; then stand up keeping your arms folded across your chest. Like this. . .". Following this introduction, survey participants were asked whether they thought it would be safe to try standing up from a chair without using their arms . Everybody completing the performance test successfully is coded as unimpaired, whereas individuals are considered impaired if they did not complete the test or if they thought it was unsafe to try in the first place. Moreover, a small percentage of individuals used their arms to stand up from the chair; this is also considered to be unimpaired. We provide sensitivity analyses in which individuals who thought it was unsafe to perform are excluded from the analysis, and a second set of sensitivity analyses in which individuals using their arms to stand up from the chair are considered as impaired . The self-reported mobility measure is based on the survey question, "Please tell me whether you have any difficulty doing each of the everyday activities [. . .]. Exclude any difficulties that you expect to last less than three months". Among other everyday activities, survey respondents could choose difficulties in "getting up from a chair after sitting for long periods". Individuals are considered impaired if they reported having difficulties getting up from a chair. Cognition indicators. Cognition was addressed with a memory test in Waves 4 to 6. Because the self-reported memory item has more than 80% missing values in Wave 6, this study only considers Waves 4 and 5. Self-reported memory is evaluated with the survey question, "How would you rate your memory at the present time?", which was answered on a Likert scale with categories excellent, very good, good, fair, and poor. Every individual reporting fair or poor memory is considered impaired [30]. The memory performance task reports the ability to immediately recall as many words as possible. The interviewer reads aloud a list of 10 words and asks the survey participant to recall as many of the words as he or she can within 1 minute, in any order. In this study, individuals are considered to be cognitively impaired if they recall only three words or less [31,32]. Additionally, in robustness analyses, individuals are considered impaired if they recall only two or fewer words . Since the subjective memory question might refer to immediate and delayed memory, we conduct an additional sensitivity analysis in which we operationalise objective cognition with delayed word recall . --- Determinants of concordance Scientific studies on health-related questions as well as governmental health reports usually include separate analyses for one or more subpopulations. The subpopulations that are most commonly compared are individuals from different countries, different genders, age groups and educational groups. Often, these analyses are based on self-assessed health data, which is crucial since these demographic characteristics are frequently identified in the literature as important factors of health misreporting [11,13,14,16,17,33,34]. For example, [14] showed that variations in self-assessed health between European countries would be much smaller if all countries had the same reporting behaviour. These disparities are explained by cultural differences in reporting behaviour, different perceptions of how restricting poor health is and compositional differences [11]. It was also shown that older individuals often overestimate their health [35], possibly due to peer effects [36]. Some evidence suggests that women tend to underestimate their health [9], which could be related to them reporting limitations more frequently [37][38][39]. However, other studies find no effect of gender on reporting behaviour [15]. Finally, evidence on educational attainment shows that highly educated older Europeans are more likely to rate their health state negatively and that consequently, health inequalities appear lower than they actually are [16]. Similar results were found for non-European countries [33]. Based on the observation that demographic characteristics are most commonly used for comparative health studies, and that the same characteristics are associated with deviations in reporting behaviour, this study focuses on the main demographic characteristics only . In accordance with the International Standard Classification of Education, education levels are combined into three groups [40]. The group of low education includes everyone with lower secondary education and less. Medium education refers to survey participants with upper secondary or post-secondary nontertiary education, and tertiary education includes individuals with tertiary education. Age is operationalised as a categorical variable, grouping 5-year age groups. Only participants between the ages 50 and 94 are considered, resulting in a total of nine age groups. In addition to the main demographic characteristics, other individual factors such as marital status, parenthood or employment status might contribute to or mediate the effect of demographic characteristics on reporting behaviour. For example, employment status might impact health perception since persons working in analytical jobs experience their level of cognition regularly and persons conducting manual labour are likely aware of their mobility impairments. The employment status of older Europeans is highly correlated with their age, since most individuals exit the labour force at a set retirement age. Thus, parts of the effect of age on reporting behaviour might be due to differences in the employment status. Furthermore, employment might also mediate the effect of education on health perception, since highly educated individuals are more likely to work in jobs that require strong cognitive skills. While results for such subordinate channels are not presented in the main document, supplementary analyses including additional determinants are provided in S1 Appendix. --- Methods We first investigate trends with descriptive statistics. Following this, the relationship between demographic characteristics and the probability to overestimate or underestimate health is estimated. Finally, a relative importance analysis highlights the magnitude of each explanatory variable's contribution to the overall reporting bias. The empirical strategy employed is based on a recent study by Angel et al. [41], who analysed the reporting bias in survey-based income data. All of our analyses are first applied to indicators of mobility and then to indicators of cognition. --- Multinomial logistic regression A multinomial logit model is applied to estimate the effects of demographic characteristics on the probability to overestimate or underestimate health. The characteristics of interest are gender, age, education, and country of residence. In addition, we control for the survey wave to account for potential time effects. The outcome variables used in the regression models are three-category variables that indicate if an individual overestimates his or her health, underestimates his or her health, or achieves concordance between performance-tested and self-reported indicators. Concordance is used as the reference category; hence, the log odds of the variables explaining overestimating and underestimating have to be interpreted relative to the outcome category of concordance. More specifically, the non-linear baseline models are as follows: ln Pðy ¼ over À estimatingÞ Pðy ¼ concordanceÞ � � ¼ b 1:0 þ b 1:1 COUNTRY i þ b 1:2 AGE i þ b 1:3 EDUC i þ b 1:4 GENDER i þ b 1:5 WAVE i þ ε ið1Þ ln Pðy ¼ under À estimatingÞ Pðy ¼ concordanceÞ � � ¼ b 2:0 þ b 2:1 COUNTRY i þ b 2:2 AGE i þ b 2:3 EDUC i þ b 2:4 GENDER i þ b 2:5 WAVE i þ ε ið2Þ COUNTRY i is a dummy variable indicating the country of residence of each individual with the reference country being Slovenia. AGE i indicates the 5-year age group of individual i with age group 60-64 as the reference category. The binary variable GENDER i is 1 if the survey participant is female. EDUC i is a three-category variable, and medium education serves as the reference category. WAVE i is a dummy variable indicating the respective survey wave. When analysing mobility, the reference category is Wave 2; when analysing memory, the reference category is Wave 4. The standard errors are clustered at the individual level since respondents could participate in more than one wave. First, models 1 and 2 are estimated for the pooled sample including all countries. Then the models are estimated for each country separately to analyse how the effects vary by country. In the country-specific estimations, the wave dummies are only included if the respective country participated in both waves. --- Relative importance analysis To analyse the contribution of individual characteristics to the overall bias in self-reported mobility and cognition, relative importance analysis is conducted. More specifically, the fit statistics of the regression models are decomposed to evaluate how much of the variation in concordance, overestimating, and underestimating is explained by the regressors COUNTRY i , AGE i , GENDER i , EDUC i , and WAVE i . We utilise the user-written programme domin for Stata to calculate the relative contributions [42,43]. For this purpose, different models with all possible combinations of the five explanatory variables except the constant-only model are estimated. The fit statistic, in our case a Pseudo R 2 , varies depending on the constellation of the regressors. Based on this variation, the relative contribution of each explanatory variable can be computed. Importantly, only explained variation can be decomposed. Hence, only the contribution of variables actually included in the model can be quantified. We calculate the relative importance of each explanatory variable in the pooled model, as well as in the country-specific models. --- Robustness analyses In addition to the main model specification described above, we provide robustness analyses in S1 Appendix to analyse if the results are sensitive to the definition of physical and cognitive impairment, sample composition and model specifications. First, we control for additional variables to analyse the robustness of the estimated coefficients. In particular, we add employment status, a dummy variable that indicates whether the survey participant has children, and a dummy variable that indicates whether the individual is married or in a registered partnership to the models . Furthermore, education is interacted with gender to determine if the effects of education vary with gender . We also investigate whether learning effects influence the estimates. That is, when individuals had their mobility or memory tested in a previous wave, they might be more likely to achieve concordance in a subsequent wave. To control for a potential learning effect, dummy variables are added to the model, which indicate if an individual performed a test in any wave prior to the one investigated . We also analyse whether the results are sensitive to the definition of mobility impairment. In particular, we investigate whether the results change when individuals that have to use their arms to stand up from a chair are considered impaired or when individuals that refuse standing up from a chair are dropped from the analysis . We also investigate whether the results are robust to different thresholds defining memory impairment . Furthermore, we use delayed word recall instead of immediate word recall to operationalise memory for a sensitivity analysis . Finally, we investigate if the results are robust to different sample compositions. First, all frail individuals are excluded from the sample [44,45]. This allows us to account for the fact that frail individuals might be more likely to live in institutions in some countries than in other countries and consequently are not always included in our target population. These differences in sample compositions could alter the results, if poor health has an impact on reporting behaviour . Second, we run the models on the exact same sample for both health dimensions. For the main analysis, Wave 2 and Wave 5 are utilised to estimate concordance of mobility measures, and Wave 4 and Wave 5 are utilised to estimate concordance of cognition measures. Since we want to compare the results for concordance of mobility and cognition measures, we also compute estimates based on Wave 5 only, which provides data for both health dimensions. Thus, we ensure that differences between the two samples are not mistakenly interpreted as differences in reporting behaviour . --- Results on mobility --- Descriptive results When asked about their mobility, 19.2% of the survey participants report difficulties getting up from a chair after sitting for long periods. However, when tested, only 17.2% are unable to stand up from a chair or considered it unsafe to try. Overall, 80.4% of the survey participants show concordance between their reported and tested mobilities, yet the outcome varies substantially by individual characteristics. Men are more likely to report their actual level of mobility than females, mainly because women tend to more frequently underestimate their health. Interestingly, 12.0% of all women rate their mobility lower than it actually is compared to 7.9% of all men . Concordance strongly declines with age. In the 50-54 age group, 85.5% report their correct level of mobility, but in the 90-94 age group, only 65.6% achieve concordance. Overestimating increases from 7.1% at ages 50-54 to 24.7% at ages 90-94. Underestimating increases less steeply and not linearly from 7.4% to 9.7%. There is also a clear education gradient in reporting behaviour. Highly educated individuals are more likely to achieve concordance than less-educated individuals . In addition, the less educated more often overestimate their health, whereas the highly educated more often underestimate their health. Finally, concordance varies strongly between countries. Overall, it is much higher in Northern and Western European countries than in Southern European countries, Central and Eastern European countries, and Ireland. Denmark has the highest average concordance of 87.7%, and Poland has the lowest with only 70.4%. The variation in concordance may stem from differences in overestimating rather than underestimating, as participants from Southern and CEE countries as well as Ireland tend to strongly overestimate their mobility. Furthermore, all Southern countries are less likely to underestimate their ability to stand up from a chair. --- Regression analysis Most findings from the descriptive analysis are confirmed by regression analyses for both the pooled sample with all countries as well as the country-specific samples ; in regard to overestimating, the gender effects are small and appear insignificant once we control for employment, marriage or an interaction effect between education and gender as well as once participants that felt unsafe are excluded from the sample . Similar to the descriptive results, the regression results indicate a clear education gradient in concordance. Less-educated participants are 1.2 times more likely to overestimate their mobility and also 1.2 times more likely to underestimate their mobility compared to individuals in the medium education group. On the contrary, participants with a tertiary education have a lower tendency to both overestimate and underestimate mobility . There is also an interaction between gender and education, where less-educated women in particular are prone to underestimating their ability to stand up from a chair . Similarly to age, the education gradient in concordance appears less steep once employment is controlled for, which supports the hypothesis that parts of the education effect are due to educational differences in employment . Fig 2 presents the rates of concordance, overestimating, and underestimating by country. Overall, there is a tendency for higher concordance in Western and Northern European countries. By contrast, individuals in Southern European countries, CEE countries, and Ireland are less likely to achieve concordance, mainly because they tend to more often overestimate their mobility. The tendency to underestimate mobility is more evenly distributed among countries, yet there are still differences. For example, Southern Europeans underestimate their health less often. Finally, the coefficient for the survey waves indicates that survey participants are less likely to overestimate their mobility in 2013 compared to 2006/2007 . The coefficient decreases after controlling for potential learning effects, but still remains significant . This could be due to cohort effects, but it is not possible to disentangle cohort effects from period effects using the present dataset. A second explanation for the significant time effects could be that some countries changed their interview procedure between the two survey waves. When estimating models 1 and 2 for the country-specific samples, the results from the pooled model are confirmed. However, standard errors are larger due to the smaller sample sizes, leading to less significant results. The output tables for the country-specific estimations can be provided upon request. Furthermore, the results are robust to different specifications of impaired mobility as well as to different sample compositions . survey wave, the estimates of time effects for these countries are not provided. For the majority of the countries, age is the single most important characteristic explaining the bias of selfreported health. Depending on the country, either education or gender comes second. The contribution of time effects is negligible in most countries, except for France, Germany, and Italy. As discussed earlier, these time effects could be due to unobserved cohort effects, or because these countries changed their interview process between Wave 2 and Wave 5. --- Results on cognition --- Descriptive results When asked about their memory, 29.4% of all survey participants report cognitive impairment , yet when tested, only 16.1% recall three words or less. Overall, 71.8% of the participants show concordance between their reported and tested memories, but there is no clear difference between genders except for a slight tendency for men to overestimate and for women to underestimate their cognition. Concordance between mobility and cognition measures is highly related. According to Chi-squared tests, individuals that are prone to overestimate one dimension are also more likely overestimate the other; the same holds for underestimating and concordance. Similar to mobility, there is a strong decline in concordance with age. While 80.6% of the 50-54 age group report their correct level of memory, only 63.9% of the 90-94 age group achieve concordance. Misreporting is even more pronounced at ages 80-84, in which 61.4% show divergence between tested and self-reported measures. Unlike mobility, it is not clear from the numbers whether the decrease in concordance with age is due to an increase in overestimating or underestimating. While the tendency to overestimate cognition increases steadily with age, under-estimating is highest at ages 75-79 and decreases thereafter. There is a pronounced education gradient in the concordance between tested and selfreported cognition, where again Western and Northern countries have lower discrepancies. Switzerland has the highest rate of concordance and Estonia has the lowest . However, the division is not as clear as for mobility, mainly because Sweden has a relatively low rate of concordance , similar to that of Slovenia and Czechia. --- Regression analysis Regression analyses also show concordance decreasing strongly with age . Individuals aged 80-84 are three times as likely to overestimate their memory than the reference group of 60-to 64-year-olds . The oldest individuals, aged 90-94, are 3.7 times as likely to overestimate their cognitive ability . Similar to mobility, the probability to underestimate memory increases up to ages 75-79 , but slightly decreases again for the oldest individuals. Based on the country specific samples, S2 Fig provides the values of concordance by country and age. Contrary to mobility, the strong age gradient in concordance does not change once employment is controlled for . The effect of education on concordance is even stronger for cognition than it is for mobility. Less-educated participants are 1.9 times more likely to overestimate their memory and 1.3 times more likely to underestimate their memory . Tertiary education is associated with a lower probability to both overestimate and underestimate cognition . These results remain robust even after controlling for employment . Contrary to mobility, women are less likely to overestimate their memory than men . However, females are slightly more likely to underestimate their cognition in the pooled model. In the country-specific estimations, this finding holds for Belgium, Estonia, France, Italy, Portugal, and Spain. However, in Austria, Denmark, and The Netherlands, women are less likely to underestimate their memory. The gender differences increase when memory impairment is based on delayed word recall, which indicates that women and men either interpret the subjective memory question differently, or relationship between immediate and delayed word recall differs between genders . Concordance between tested and self-reported cognition differs among the countries observed. Again, Southern European and CEE countries have lower rates of concordance than Western and Northern European countries . Two exceptions are Czech Republic, which achieves a relatively high rate of concordance, and Sweden, which achieves a medium level of concordance. As with mobility, the tendency to overestimate cognitive ability is much greater in Southern and CEE countries. Interestingly, participants of Wave 5 are less likely to overestimate and instead more likely to underestimate. This finding does not change when additionally controlling for a potential learning effect . As with mobility, this could indicate a cohort and/or time effect or differences in the interview procedure over time, both of which the available data cannot account for. Finally, all results are robust to changes in the threshold of cognitive impairment , to differences in the sample composition as well as to different model specifications . --- Relative importance analysis The bias in self-reported cognition is mainly due to differences in reporting behaviour by country, which explain 44.9 per cent in the pooled model. Differences by age group contribute 29.7 per cent to the explained variation. Education is much more relevant in explaining the reporting bias in self-reported cognition than it is for measures of mobility. Variations in reporting behaviour by gender and survey wave are even less important for self-reported memory than they are for self-reported mobility. This finding holds also when estimates are based on Wave 5 only . Fig 5 shows country specific decompositions of the fit statistic. Age is still very relevant for explaining the reporting bias in cognition measures, yet education is just as important in some countries. On the contrary, gender and wave are neglectable when it comes to explaining the reporting bias. Two exceptions are Estonia and Austria, where the survey wave seems to contribute to the explained variance. Similar to the results on mobility, these exceptions could either be due to cohort effects, or because interviews were conducted differently in Wave 4 and Wave5. --- Discussion In this study on older Europeans, we investigate the discrepancy between tested and selfreported health measures and explore which demographic characteristics are most important in explaining health misreporting. In particular, we focus on the demographic characteristics most frequently used for health comparisons, namely country of residence, gender, age and educational attainment. Furthermore, we investigate subordinate channels that might explain or mediate the effect of demographic characteristics on reporting behaviour, particularly employment status, parenthood and marital status. Conducting a relative importance analysis, we find that differences in reporting style between countries and age groups explain most of the bias in self-reported health. These findings suggest that comparisons of health between countries and age groups based on subjective data have to be treated particularly careful. In addition, for self-reported cognition specifically, misreporting varies substantially between educational groups. Parts of the strong age and education effects on reporting style can be explained by differences in employment by age and education. Parenthood and being married, however, add little to the bias. Sensitivity analyses show that the results are robust to changes in the definition of physical and cognitive impairment, sample composition and model specifications . Concordance as well as the tendency to overestimate and underestimate health vary strongly across Europe. Results from the relative importance analyses show that 35% of the reporting bias in mobility and 45% of the bias in memory are due to differences in reporting behaviour between countries. Overall, Northern and Western European countries have fewer discrepancies than CEE or Southern European countries. Southern Europeans seem particularly prone to overestimating their health, which is contrary to the results of [14], who finds that Scandinavians overrate their health the most. Previous studies also identified country differences in reporting style for European countries [14,46,47], low-and middle-income countries [4], as well as within countries and across subpopulations [5]. It was shown that selfreports are influenced by culture-specific reporting behaviour, compositional differences between countries and differences in the perception of how restricting poor health is [11]. In addition, the strong country effects could also be due to different health care policies. For instance, the proportion of elderly persons in residential care varies across Europe, thus frail persons might be sampled differently across countries. If frailty affects response behaviour, different shares of frail individuals in the country samples could explain differences in aggregated concordance. We controlled for this possibility by excluding all frail individuals from the analysis, yet the results remained robust . Speculatively, the between-country discrepancies could also be due to differences in regional development. For a subset of our country sample, early results on the relationship between a regional developmental index [48] and discrepancies in mobility suggest that countries with better living conditions show more concordance than their counterparts. However, further research with data on the whole lifecycle is needed to investigate the potential development effect properly. In addition to the cultural bias in self-reported data, we find a strong decrease in concordance with age for both health dimensions. This result is in accordance with earlier research on several physical performance measures [6][7][8]. Further, previous research supports our finding that subjective health measures of older individuals are often upward biased [35]. One explanation could be that octogenarians and nonagenarians tend to compare their health status with peers suffering from worse health, which enables them to maintain a positive perception of their own health state [36]. This so called downward comparison makes older persons feel more satisfied with their lives, especially, when they are frail themselves [49]. Resilience strategies like these help individuals to flexibly adapt to changes of their physical and cognitive health while maintaining a positive self-image [50]. Overall, the age-related decline in concordance between performance based and perceived memory measures is robust to controlling for employment . However, concordance between mobility measures declines less steeply with age once the employment status is considered. This indicates that a part of the strong age effect is due to variation in the share of employed persons across age groups. The causal direction, however, remains unclear. It could either be that employed individuals are more aware of their physical ability, or that persons that are more aware of their own health status are more likely to be employed. Thus, future studies could fruitfully explore the interrelations between health perception, age and employment. We also identify a clear education gradient in concordance for mobility and an even stronger effect for cognition. Less-educated individuals tend to misreport their mobility and memory more frequently, whereas the highly educated are less likely to misreport. Previous research does not provide conclusive results on this matter. Some studies report that higher education results in a more optimistic view on health [8], while others find the exact opposite [33,51,52] or no significant education effect at all [53,54]. Overall, our results on education can be interpreted as additional evidence for the phenomenon that higher educated individuals have higher health awareness and literacy [55,56]. For example, higher educated are more familiar with the risks of tobacco smoking [57], less likely to misjudge their weight [58] and, as shown in this study, also less likely to have a biased view on their physical and cognitive abilities. Since health literacy is an important determinant of health behaviour and consequently health itself [59][60][61], enhancing health literacy of low educated individuals could improve their health outcomes. It may also be hypothesised that the gender gap in the education of older Europeans contributes to differences in misreporting. On average, men at advanced age are higher educated than women within our investigated cohorts. What supports this hypothesis is our finding that less-educated women are particularly prone to underestimate their mobility . In addition, employment status at higher ages varies by gender and education with higher educated being more likely to work longer [62]. Our robustness analyses showed that the education gradient in concordance appears less pronounced for mobility once employment is accounted for, but interestingly does not change for cognition . The educational differences in cognition only changed when delayed word recall is used and education is less important to explain the differences . We also find differences in reporting behaviour between men and women, but they are less pronounced and explain very little of the overall reporting bias. In particular, women tend to underestimate their health more frequently in both health dimensions. One explanation for these gender differences might be the tendency of women to report limitations more frequently [37][38][39], while men tend to underreport their health status [63]. Recent research also showed that reporting morbidity was more legitimate in female-dominated work environments, indicating an association of gender norms with gender difference in reporting behaviour [39]. This might also be related to women looking for medical advice more often than men [64,65]. Interestingly, our findings on overestimating health vary by health dimension with women being less likely to overestimate their memory than men, but being more likely to overestimate their mobility. Moreover, difference between genders increases when delayed word recall is instead of immediate word recall, which indicates that women and men might interpret the subjective memory question differently. Our small and sometimes ambiguous gender effects are in line with the literature, which does not provide conclusive results either. While some studies comparing self-assessed and clinical data find clear evidence that women are more likely to overestimate their health [66], others identify women to be more likely to underestimate their health [67,68]. A recent study based on SHARE data found no clear gender-specific pattern in reporting behaviour [15]. In general, our results not only give guidance on how to carefully interpret self-reported health measures, but might also contribute to a reduction in adverse health outcomes due to mistaken self-assessments. For instance, overestimating lower body functioning might contribute to higher risks of fall-induced injuries [10]. Further, overestimating cognitive abilities might result in illusory self-awareness of everyday functioning [69]. In psychology, the consequences of wrong self-awareness of cognitive abilities are discussed as the Dunning-Kruger effect, which states that unable individuals are especially prone to overestimate their abilities [70,71]. If the tendency to overestimate ones physical and cognitive capacity has an adverse impact on health-related behaviour of older Europeans, then awareness should be created in particular among the oldest old, among men and among Southern Europeans. A major contribution to the literature is that we are able to compare reporting behaviour of mobility and cognition simultaneously. The results show that concordance of the two health dimensions is highly related. Individuals that are prone to misreport one dimension are also more likely to misreport the other. This indicates that correlations between the two health dimensions are, to a certain degree, due to similarities in reporting behaviour. However, we also find differences in the reporting styles of subjective physical and cognitive health. For instance, concordance is slightly higher between mobility measures than between memory measures. Furthermore, the composition of the bias in self-reports differs between the two health dimensions. The cultural bias in subjective data, i.e. differences across countries, is more relevant for cognition than for mobility. Additionally, reporting heterogeneities between education groups result in larger biases in self-reported memory than in self-reported mobility. Gender, however, explains relatively little of the bias in both health dimensions. Controlling for wave effects shows that participants in Wave 5 are less likely to overestimate their mobility as well as their cognition, even after controlling for potential learning effects. These findings indicate that cohort or time effects influence the reporting style, which is crucial since the analysis of mobility and memory are based on different waves. To ensure that the differences in reporting style of physical and cognitive health do not stem from differences in the sample composition, we conducted a robustness analysis for which we restricted our analysis to Wave 5, which is the only wave that provides relevant data for mobility and memory. Tables H and I in S1 Appendix show that the overall findings remain even after both health dimensions are analysed based on the same subsample. The main limitations of this study are threefold. First, the population composition is likely to vary across countries. We conducted robustness analyses for different sample shares of frail individuals, but additional deviations in the sample composition could also influence the results. Second, the questionnaire is conducted in the national language, which could result in some bias when it comes to self-assessed health because the wording differs across languages. Third, it appears that some of the effects are influenced by time or cohort effects, however, disentangling these effects is not feasible with the data at hands. In conclusion, self-reported measures of mobility and cognition have to be treated cautiously, in particular when comparing health across countries and age groups. In addition, the education gradient in concordance needs to be considered when analysing memory. Finally, men and women show different reporting behaviours, yet the impact of gender on the overall bias between tested and self-reported health is less pronounced than that of other demographic characteristics. --- The data underlying the results presented in the study are available from the Survey of Health, Ageing and Retirement in Europe . In particular, Wave 2 , Wave 4 , and Wave 5 are utilised. --- --- Data curation: Sonja Spitzer. Formal analysis: Sonja Spitzer. Methodology: Sonja Spitzer, Daniela Weber. Validation: Daniela Weber. Visualization: Sonja Spitzer, Daniela Weber. --- Writing -original draft: Sonja Spitzer. Writing -review & editing: Daniela Weber.

This paper explores which demographic characteristics substantially bias self-reported physical and cognitive health status of older Europeans. The analysis utilises micro-data for 19 European countries from the Survey of Health, Ageing and Retirement in Europe to compare performance-tested outcomes of mobility and memory with their self-reported equivalents. Relative importance analysis based on multinomial logistic regressions shows that the bias in self-reported health is mostly due to reporting heterogeneities between countries and age groups, whereas gender contributes little to the discrepancy. Concordance of mobility and cognition measures is highly related; however, differences in reporting behaviour due to education and cultural background have a larger impact on self-assessed memory than on self-assessed mobility. Southern as well as Central and Eastern Europeans are much more likely to misreport their physical and cognitive abilities than Northern and Western Europeans. Overall, our results suggest that comparisons of self-reported health between countries and age groups are prone to significant biases, whereas comparisons between genders are credible for most European countries. These findings are crucial given that self-assessed data are often the only information available to researchers and policymakers when asking health-related questions.

Introduction Primary and secondary care services are under increasing pressure to meet the needs of over 15 million people in England who live with a long-term condition. Long-term conditions are chronic health conditions such as coronary heart disease or diabetes which are presently incurable and managed by medication and other therapies . The notion of 'self-management' has become central to addressing the growing burden of long-term conditions, moving the day-to-day responsibility of managing health from the state to the individual, families and social groups . The needs of people living with long-term conditions are often associated with increased social isolation impacting on their physical and psychological well-being, social functioning and their ability to 'self-manage' . Responding to psychosocial problems is often beyond the capacity of health professionals whose support for patients focuses on diagnosis and health advice . Because of these limitations, health services struggle to effectively assist patients with psychosocial problems and the challenge of incorporating long-term condition management activities into their contemporary everyday lives . Although recognition of psychological and social dimensions of long-term condition management is well documented, it has remained on the periphery of health interventions . One possible means of addressing the gap between the demands of patients and the ability of traditional health services to deliver appropriate, holistic support would be to engage with the voluntary and community sector, where many health-related services such as exercise classes and support groups are provided . Furthermore, socially disadvantaged groups suffer disproportionately from chronic conditions, such as diabetes and heart disease , but are often unable to make the most of available health provisions. Barriers people face are associated with access, language, cultural appropriateness, transportation, finance and health literacy . To overcome these barriers, it has been suggested that community settings may be a more appropriate setting for health support . For instance, community health workers and peer supporters have been used to improve chronic disease care and health outcomes . However, it is unfeasible for health professionals to keep up to date and to identify appropriate community-based resources for patients within the time constraints of a consultation . Community and voluntary groups therefore often work in parallel, without explicit links with primary care. Social interventions which facilitate access from health services to appropriate community-based resources have potential for longer term health benefits. For instance, social prescribing is an approach which has gained momentum over recent years and is defined as: . . .enabling primary care services to refer patients with social, emotional or practical needs to a range of local nonclinical services. Accessing a broad range of community-based services is increasingly identified as having the potential to address the limited 'one-size-fits-all' approach to long-term condition management . This review focuses on identifying key components and benefits of social interventions, including social prescribing schemes, which facilitate access from healthcare settings to a range of communitybased resources for patients and service users to improve their health and well-being. --- Methods This review identified the literature on social interventions which link participants from healthcare services to a range of community-based resources. To date, the literature on interventions of this nature is scarce and not conducive to systematic reviews. To examine the extent, range and nature of research activity in this area, scoping reviews are more suitable as they incorporate both published and grey literature. To guide our review process, we adopted Arksey & O'Malley methodological framework for conducting scoping studies. The framework suggests five stages within the review process: Identifying the research question, where the authors identify all aspects of the research area, i.e. population, intervention or outcomes, that is most important to the review. They then iteratively focus and redefine the research question as they became more familiar with the existing literature; Identifying relevant studies, using a comprehensive strategy involving different sources, to identify and thoroughly map existing primary studies and reviews relevant to the research question; Study selection, whereby authors develop a mechanism to screen and eliminate studies from the search results that do not address the central research question; Charting the data, which involves extracting and sorting information from individual studies, according to key issues and themes; Collating, summarising and reporting results, to present an overview of all material reviewed. The flexible and reflexive nature of the five stages enabled this review to achieve a broad range of results using studies with various designs and quality. --- Stage 1: identifying the research question For this review, a social intervention was defined as: an intervention whose primary aim is to improve health and/or well-being by facilitating contact with other people, groups and community organisation. The review therefore focused on the linking mechanisms of social interventions which facilitate access to a range of community-based resources. --- Research question and objective What are the types and benefits of linking mechanisms, adopted by social interventions to support people in healthcare settings access wider community-based resources? In addressing the above question, the review aimed to consider the following objectives: 1 To identify key components of social interventions linking participants from healthcare settings to community groups and services. 2 To identify facilitators and barriers to delivering an intervention of this nature. 3 To identify key benefits provided to participants in relation to their health and well-being. --- Stage 2: identifying relevant studies The literature search was initially conducted between February and September 2011. Because of problems with resources, the review took longer than expected to complete, and a second literature search was conducted between May and June 2013 to ensure that the papers included were up to date. On both occasions, the researchers used the following databases: Ovid Medline , EMBASE , ScienceDirect , CINAHL and SpringerLink . Further studies were identified by searching reference lists of all articles and systematic reviews considered relevant, and hand searching the following journals: Social Science and Medicine and Chronic Illness. Grey literature was identified using the internet search engine Google. A pilot scoping exercise of peer models of support and community interventions for self-management identified 11,887 papers. Through discussions with co-authors, the review was refined to focus on community interventions where individuals are linked from healthcare settings to a range of community resources. This was termed as either social intervention or social prescribing, yielding an initial 959 papers. Specified search terms were used to search all databases during the initial search in 2011, while a slightly broader search strategy was adopted when updating the literature search in 2013, to ensure that any potentially relevant studies were not excluded. --- Stage 3: study selection Titles and abstracts of 2695 identified studies were assessed for relevance, and full text copies of 43 studies were obtained. RM and RLM applied the inclusion and exclusion criteria to their reading of titles, abstracts and full texts of papers . --- Eligibility criteria All studies, in which participants were referred from a health and social care setting to an intervention that aimed to support them in accessing a range of community-based resources, were eligible. Electronic journals were searched from their commencement to the present date for literature published in any country written in English. No restrictions were placed on study design or type of long-term health condition. After removal of duplicates and studies found to be irrelevant, a total of four peer-reviewed articles and three reports were included . Stage 4: charting the data Data were extracted and charted using Microsoft Excel spread sheet by RLM. Recorded information consisted of named authors, year and country of publication, target population, inclusion and exclusion criteria, description of intervention, outcome measures and its principle findings . The data extraction plan also included reported barriers and facilitators to delivering the intervention, while further ideas and themes such as the role of the health professionals and intervention facilitators emerged in the course of our familiarity with the literature. --- Stage 5: collating, summarising and reporting results The findings are presented in two ways: First, a tabulation of information regarding study population and intervention delivery and outcomes . Second, key themes that emerged from the narrative accounts within the literature were used as sub-headings. --- Results --- Overview of results A total of 2738 papers were identified through initial search of journal databases and grey literature. Full texts of 43 papers were retrieved and screened, and the findings from seven of these papers were included in the review. Three of the seven papers present findings from randomised controlled trials , two population-focused interventions and the other a referrals facilitator intervention within primary care . Three papers provide evaluations of interventions, one which is a cohort study and the other two are reports of social prescribing schemes . One other paper discusses findings from an action research project, aimed to develop a business case to seek further funding for a local social prescribing service . Information extracted, charted and reported from the papers relates to intervention population, intervention delivery, health outcomes, social outcomes, impact on health services, facilitators and barriers, and cost-effectiveness. --- Target population The interventions target a variety of different populations and conditions including mental health , social isolation in the elderly people and frequent service users in general practices . Brandling and House found that for patients who had three or more hospital referrals in the last 12 months, the strongest indicators for suitability for social prescribing were poor social support mechanisms, psychological difficulties and vague or unexplained symptoms. Another study reported that most patients referred to the social prescribing health trainers had a mental health issue, followed by lifestyle issues and social isolation . In the evaluation report of the social prescribing scheme called the community health advice team , social isolation was also the most common reason for referral . --- Intervention delivery Participants were recruited from general practices and social care services . Referrals to the linking scheme were made by a variety of health and social care professionals. In one study, social workers/home help assistants visited and interviewed participants, and organised the intervention , while referrers in other interventions were usually general practitioners providing less input in regard to its delivery . Self-referral was encouraged in combination with referral from a health professional in two interventions . Clarke et al. recruited participants to their intervention using the findings from a survey of elderly patients from 12 general practices, without the involvement of a health professional. All of the interventions except one were facilitatorled. Identification of appropriate community resources and ways to engage in the local community took place through group discussions by participants in the Ageing and Loneliness Project . Clarke et al. used 'lay community workers' situated in the community as opposed to a healthcare setting. The remaining five interventions used facilitators whose role was specifically developed as part of the intervention: graduate primary care mental health workers , SPHTs , the CHAT workers and Amalthea Project facilitators . Tools used to link intervention participants to community groups and organisations are only reported by one study. The GPCMHWs used directories, telephone enquiries and other sources to identify appropriate services for patients . Grant et al. describe the Amalthea Project as having been funded by the NHS to collect information about the voluntary sector, which was used to refer patients to local and national voluntary organisations. However, details of how the information was collected, organised and used to map patients' needs to voluntary organisations, were not provided. Similarly, White et al. and Woodall and South describe the role of the facilitators as continually keeping up to date with all the activities and services in the local community, but do not provide any description of the processes involved and the format in which the information was collected and utilised. Two papers report the proportion of participants referred to other organisations and services. SPHTs signposted 51% of patients to other organisations including literacy courses at colleges, volunteering and community allotments, line dancing and Citizen Advice Bureau . The GPCMHWs from the Community Link Scheme are reported to have signposted 88% of their patients to community services. In the Amalthea Project, 97% of participants were reported to have received an initial assessment and 80% further contact and signposted to one or more community organisations . However, the exact numbers utilising community and voluntary groups were not reported. In the RCT conducted by Clarke et al. , only 101 participants out of 260 randomised into the intervention arm received support, but there were no details of the groups and services they were referred to. Only one paper reported the number of participants continuing to access organisations they were referred to by the intervention. Grayer et al. reported that nearly two-thirds of the 58% of participants, who accessed at least one service, were still attending a 3-month follow-up. Overall, it was unclear as to the extent to which participants in these interventions had found the community-based resources they were referred to, relevant to their needs. Grayer et al. reported client satisfaction to be moderate among intervention participants at the 3 month follow-up, with satisfaction being higher among participants who contacted services they were referred to, than those who did not. The service evaluations of the two social prescribing schemes alluded to qualitative findings of participant satisfaction, which varied from very positive to quite mixed perceptions of the appropriateness of community-based resources individual were referred to. --- Health outcomes Two studies reported reduction in either depression , psychological distress or probable mental health problems . Grant et al. reported that improvements in depression measured by the Hospital Anxiety and Depression Scale were not significantly different between the intervention and the control groups. However, as anxiety and stress were the most common reasons for referral to the project, the intervention focused primarily on addressing these issues rather than on depression. They, therefore, reported a significantly greater reduction in symptoms of anxiety in the intervention group than in the control group. Grayer et al. reported that four-fifths of patients were cases with 2 scores for mental or emotional distress on the General Health Questionnaire-12 at baseline, which was reduced to half post-intervention. Three studies reported changes in the number of medications taken by patients . Patients reported a reduction in the number of medications they were taking, particularly antidepressants, as a result of seeing a SPHT because they felt more confident in dealing with social issues . Grayer et al. also found a reduction of 15.8% in the proportion of patients taking psychotropic medication who were supported by the GPCMHWs, according to their medical records. The intervention patients in the Amalthea Project, however, were found to have received more prescriptions for all drugs, particularly mental health drugs . While the primary focus of all studies addressed psychosocial problems, three studies reported measuring physical health status. For instance, a majority of the patients in one study decided to focus on their mental health and well-being and very little is reported on changes to patients' physical health status. Clarke et al. reported no statistically significant difference in mortality and changes in physical status measured by the Activities of Daily Living Index at 2 years. However, a significantly greater proportion of intervention participants perceived their health status to have improved compared to control participants . Grant et al. also reported a number of physical health outcomes in their trial. Using the COOP/ WONCA Functional Health Assessment chart, they reported greater improvement in pain , feeling , daily activities , change in health and overall health in the intervention group than in the control group. However, statistical significance was not found for improvement in physical fitness on the assessment chart. --- Social outcomes Reduction in social isolation and feelings of loneliness were reported by four studies . Andersson found a statistically significant improvement in the frequency of social contacts and number of leisure activities in the intervention group participants. Loneliness, using the Wenger Loneliness Scale, and frequency of social contacts were also measured by Clarke et al. . Although neither measure of loneliness was statistically significant, the median, minimum and maximum social contact scores for the intervention group increased compared to the control group. The DUKE-UNC Functional Social Support scale used by Grant et al. found no beneficial effect on intervention patients' perceived social support. Grayer et al. recorded 28.7% of their referrals to be socially isolated, but did not monitor changes to social isolation post-intervention. Furthermore, White et al. reported that some participants took up volunteering in the community as a result of participating in the intervention. This was a socially significant outcome for a substantial proportion of their participants who were either unemployed or long-term sick/disabled . Similarly, 74% of referrals to the Community Link Service were unemployed and the intervention improved patients' work and social adjustment scores, from 25.63 at baseline to 21.94 at the 3 month follow-up. Increased social support, companionship, courage, motivation and awareness of local services were also identified as key achievements of interventions in the qualitative findings of studies exploring participants' experiences . --- Impact on contact with health services The impact of interventions on health service use was variable. Grayer et al. reported a significant reduction in the recorded number of patient appointments with GPs and other practice staff , mean number of consultations with a psychosocial aspect and proportion of patients with prescriptions for psychotropic medicine at 3 months post-intervention. In the studies by White et al. and Woodall and South , patients and practice staffs reported a reduction in primary care attendance, particularly from high consulters, and a decrease in social issues brought up in consultations. Grant et al. , however, reported equal numbers of primary care contacts for control and intervention arms. While Grant et al. reported fewer referrals of intervention patients to other services, including mental health services, Grayer et al. observed a significant increase in referrals to mental health services in the intervention group from 8% to almost 20%. The authors suggested that this increase was suggestive of an improvement in the detection and treatment of mental health in primary care as a result of the intervention. Similarly, the role of SPHTS was woven into an existing stepped care system, allowing referral between the scheme and other services within the mental healthcare pathway. Clarke et al. reported that contact with GPs remained the same, but highlighted a slight increase in patients' use of district nurses, home helps and home delivery of meals, which they related to changes in the provision of health and social services, and the wider socioeconomic environment beyond the control of their study. --- Facilitators to implementing social interventions In six of the seven studies, it was a health or social care professional, including GPs, social workers and practice nurses, who screened patients for suitability before referring them to the intervention for further assessment. The only study in which patients were recruited through direct contact by intervention staff reported a much higher percentage of participants refusing to take part in the intervention . All papers discussed the role of the facilitator and the relationships they established with participants. Key characteristics of facilitators identified in the studies were skills in tailoring activities to the needs and preferences of participants , and the ability to encourage attendance and flexibility in their approach . Engagement of participants was achieved by the relationship facilitators developed with them through being flexible, trustworthy, empathetic and accessible . Home visits to participants unable to attend appointments, and accompanying participants to community organisations, was an example of the flexibility demonstrated by SPHTs and CHAT workers in the social prescribing schemes . The SPHTs were purported to be skilled in communicating with the public, empowering people to come up with their own solutions to problems and providing personalised care . Developing relationships with both clinicians and voluntary and community groups was also considered an important responsibility for the facilitators to develop the profile of the intervention . The single point of contact provided by facilitators based within the general practice was reported by healthcare staff as making the referral process easy and straightforward . The physical placement of facilitators was important in ensuring effective engagement of healthcare staff, as staff at the general practice hosting the CHAT social prescribing scheme felt reassured that confidential information did not leave the practice upon referral of patients to the scheme . Adequately staffed interventions based within healthcare settings enabled facilitators in both the Amalthea Project and CHAT social prescribing scheme to see patients within 7 days of referral. --- Barriers to implementing social interventions Barriers to the implementation of social interventions included: ambiguity of facilitator role when based in GP surgeries ; inappropriate referrals to the services ; clinicians' apprehensions about referring to voluntary organisations and the sustainability of services . Playing a dual role, SPHTs expressed conflicting pressure of integrating with the practice team and also continually engaging and keeping up to date with community groups and activities . Similarly, some SPHTs did not feel fully accommodated by primary care services in terms of provision of reasonable physical space and clinical supervision . Also, while one study reported reservations on the part of GPs in referring their patients to the intervention , another reported inappropriate referrals of patients with very severe mental health problems to the social prescribing scheme . Grayer et al. reported that 21 of 255 referrals made to GPCMHW were inappropriate, with half of these referrals requiring specialist service. The referral process was briefly addressed by Brandling and House who found two out of three practices unable to identify frequent attendees using their practice computer system to determine patients' suitability for social prescribing. Although two of the studies provide encouraging evidence of efficiently responding to patients, the GPCMHWs saw patients after a mean waiting time of 22.18 days post-referral . The SPHTs had so many referrals; there was an 8-week waiting list at one practice, while referrals were temporarily halted at another . Engagement and retention of participants proved a challenge in some of the studies. Clarke et al. reported that over 50% of participants in the intervention arm either refused, died or moved away before taking part. Similarly, drop-out rates of intervention participants were at 35% and 41% in the studies by Grayer et al. and Andersson respectively. However, all patients in the intervention arm of the Amalthea Project attended baseline assessment and only 18% dropped out in the first month of receiving support. Clarke et al. explained that participants who refused the intervention were among those who were physically most independent, and perhaps perceived the intervention as irrelevant to their needs. A smaller proportion of participants who either moved away or died were on the other hand, highly dependent due to the severity of their illness and were already in contact with many services. Drop-out rates in the two studies targeting the elderly population were relatively higher than those targeting a younger population with a mean age between 40 and 50 years . The elderly population, targeted by Clarke et al. and Andersson were less inclined to make lifestyle adjustments unless it was directly warranted by declining health, but were also often too restricted by ill-health to take part in activities outside the home. The rate of withdrawal in the study by Grayer et al. was higher than that in the study by Grant et al. , although they both targeted a similar patient population in terms of age, gender, and clinical and social problems. Possible explanations for this are that patients referred to the GPCMHW service had a mean waiting time of nearly 23 days before their initial appointment, compared to a maximum of 7 days in the Amalthea Project . Other patient-reported barriers included transport , literacy , confidentiality and disclosure in voluntary groups, and also appropriateness, availability and accessibility of the activities . --- Cost-effectiveness One study measured the cost-effectiveness of the project . In this project, they used a 'liaison organisation' called the Amalthea Project, to facilitate contact between patients in primary care with psychosocial problems and voluntary organisations. The mean cost of the intervention arm was significantly greater than the normal GP care , but there were also significantly greater improvements in levels of anxiety, ability to carry out everyday activities, other emotional feelings, feelings about general health and quality of life. --- Discussion Having used the scoping review framework, this review included seven papers representing both peerreviewed and grey literature on social interventions which aimed to link participants from health and social care settings to community-based resources to improve their health and well-being. The findings highlight important aspects pertaining to the design and delivery of these interventions as well as patientand service-level benefits gained. Social interventions which propose to link participants from healthcare settings to community-based resources are also known as social prescribing. The interventions included in this review were all developed on the premise that tailored access from health services to wider community-based resources has the potential to address people's psychosocial problems. The interventions, therefore, generally targeted participants experiencing age-related loneliness, general anxiety and depression. A key theme which emerged from this review was that in almost all the papers, it was found that health professionals played an important role in referring patients to the interventions and in introducing the notion of utilising community groups with aspects of health management. Perhaps, because of familiarity with the health professional and because the referral was likely to have been made within the context of regular care, this notion was legitimised from the patients' perspective. Proximity to health professionals was therefore considered important for facilitators to develop and maintain an effective relationship with health professionals to achieve successful referrals. The review highlights the pivotal role played by the facilitators in delivering the intervention. Facilitators were trained to screen and assess participants' needs and accordingly refer, and often accompany, them to wider community-based resources. Facilitators also needed to develop and maintain relationships with health professionals as well as community and voluntary groups. Conducting assessments with participants ensured that discussions and identification of community resources were tailored to participants' needs and interests . Thus, along with offering information about local groups and services, one intervention provided participants the opportunity to develop personal action plans . Supporting participants to find solutions to their problems was an important component of the facilitation process and enhanced the uptake of activities. As the focus of all the interventions in this review was to address psychosocial issues, the impact of interventions on participants was measured and reported in terms of psychological and social outcomes. The most positive findings from the interventions were reduction in social isolation and increased social engagement for participants. Such interventions therefore have the potential to counteract the negative impact of long-term conditions on people's social lives. In terms of health benefits, there is evidence of a reduction in psychological problems reported as psychological distress, mental health problems or anxiety. Many of the interventions reported positive impacts on patients' use of medication and health services. Little attention was given to participants' physical health and there was mixed evidence about the effectiveness of the interventions on improving physical health status. It would have been interesting to know whether psychosocial benefits experienced by participants from engaging in community-based activities cascaded to have a similar impact on their physical health. Moreover, according to one study, potential participants' physical health can also determine their decision about whether or not to participate in the intervention in the first place, but as all the studies did not report on physical health status, it is difficult to draw any conclusions. In addition, the evaluations of interventions only measured shortterm health impact. As social prescribing adopts a holistic approach to health and well-being, a longer follow-up period for the evaluation of health-related outcomes may have alluded to more positive long-term benefits associated with community participation. --- Strengths and limitations One strength of this review was the use of the scoping review methodology that enabled a review of a wide range of both peer-reviewed and grey literature. The iterative thematic analysis of the literature used to identify key components in the delivery of the interventions also further strengthens the review. A limitation of this review was the heterogeneity of the interventions and populations within the literature. There were also very few peer-reviewed papers that examined social interventions that aimed to link people from primary care to community-based resources. Similarly, two of the seven articles included in the review are comparatively old , while one is based outside the United Kingdom. However, as this review focuses on the linking mechanisms of social interventions, the authors concluded that both these studies were relevant to the review despite their age and country in which they are based. Furthermore, they shared many similarities with social prescribing schemes, such as targeting socially isolated people with the aim of engaging them in their respective communities to improve their health and well-being. Finally, the articles included in the review did not differentiate between the impacts of different types of communitybased resources participants were referred to. --- Conclusion Drawing on resources within the voluntary and community sector is a potentially valuable way to support people with long-term health problems and has long been considered as a way to tackle health inequalities . The normality of participating in local activities and its associations with everyday life offers a potentially sustainable way for people to manage their health needs and reduce health service utilisation. However, it became apparent in the course of this review that very few social interventions, like social prescribing schemes, have been empirically evaluated. They were mainly identified through a grey literature search. A number of empirical studies were found on either arts on prescription or exercise on prescription, but these programmes did not connect participants to a range of groups which have been identified as a way to address the limits of current self-management support. Furthermore, of the four empirical studies, only two were of interventions assessed by a RCT , suggesting a limited evidence base for interventions of this nature. Nonetheless, from the available evidence, this review shows some promising results which are worthy of further investigation. In particular, there appears to be some credible psychosocial benefits for patients with mental health problems who are referred to community activities. The review also highlights the linking mechanisms inherent in such social interventions. This could be used to inform further work for service providers who wish to take this approach to support people with long-term health problems. ---

A scoping review to understand the effectiveness of linking schemes from healthcare providers to community resources to improve the health and wellbeing of people with long-term conditions http://researchonline.ljmu.ac.uk/id/eprint/2942/ Article LJMU has developed LJMU Research Online for users to access the research output of the University more effectively. Copyright © and Moral Rights for the papers on this site are retained by the individual authors and/or other copyright owners. Users may download and/or print one copy of any article(s) in LJMU Research Online to facilitate their private study or for non-commercial research. You may not engage in further distribution of the material or use it for any profit-making activities or any commercial gain. The version presented here may differ from the published version or from the version of the record. Please see the repository URL above for details on accessing the published version and note that access may require a subscription.

Introduction Inter-state conflicts usually start with a declaration of war and end with surrender, negotiation or an armistice between the belligerents. By contrast, many modern conflicts are seemingly intractable. This trend is particularly evident in the Sahel-Sahara region in North and West Africa, a battleground for Islamists seeking to impose sharia, rebels seeking independence, transnational traffickers, and former colonial powers looking to project influence. While many Sahel-Saharan countries oscillate between periods of rebellion and political unrest, and periods of peace and reconciliation, the actual location and onset of violence defy prediction. Long considered a poster-child of political stability, Mali, for example, faced a military coup, a rebellion, a Western military intervention, and several major terrorist attacksall in less than 2 years. By contrast, Chad, plagued by civil war and rebellion until the end of the 2000s, has been experiencing an unexpected period of stabilityit is among the very few destinations in the Sahara that is still considered safe for tourists . Against this background, this article examines the relationships between alliances and conflicts as a putative explanation for the apparent unpredictability of many modern wars in the Sahel-Sahara. Social scientists have long been preoccupied with the logic of violence, explaining the presence and absence of violent conflict, and the onset and diffusion of internecine violence. Ostensibly, these are important questions to answer if we hope to prevent and forestall violent conflict. However, in the Sahara-Sahel these models seem to have little explanatory traction: although they vary, the preconditions for violent conflict are omnipresent, yet violence itself seemingly eludes prediction while actual patterns of violence are volatile. Recent research on the social determinants of conflicts in political geography has shown that political allegiances in the Sahel-Sahara were fluid and largely not ideologically motivated . Armed groups split and coalesce unpredictably, change names as new opportunities arise, and morph as ephemeral coalitions between tribal and ethnic groups. A similar volatility characterizes commanders and rank-and-file fighters who frequently shift allegiances among regular forces, rebel movements, and violent political organizations , depending on local circumstances . The initial objective of this article posits a relational approach to the study of the structure of relationships among state and non-state actors. In doing so, it harnesses network theory for which social phenomena such as political violence are necessarily mediated by social interactions . Drawing on a public collection of data on political violence, the article uses network science to represent alliances and conflicts between 179 organizations involved in violent events between 1997 and 2014. Owing to the fundamentally relational nature of internecine violence, we are particularly interested in the way the structural positions of conflicting parties affect their ability to resort to political violence. To this end, we combine two spectral embedding techniques that have previously been considered separately: one for directed graphs that takes into account the direction of relationships between belligerents, and one for signed graphs that takes into consideration whether relationships are positive or negative between groups. Our second objective is to analyze the spatial patterns of violence across the region by localizing violent events and studying the geographic scales of regional dynamics. The literature presumes that borders matter because they circumscribe sovereign territories that impose transaction costs on those who cross. But do borders matter to Islamist groups in the Sahel-Sahara region? If so, what are their effects? And what transaction costs, countervailing or otherwise, do they impose on the movement of Islamist groups? In a geographical environment where populations remain poor and sparse, recent research on the spatiality of conflict in the region has established that cross-border mobility was an important component of military strategy . Armed groups such as Al Qaeda in the Islamic Maghreb capitalize on marital, political, and financial ties throughout the region to attack targets, take hostages, and evade security forces . These general principles of desert insurgency based on mobility, speed and range challenge the Clausewitzian conception of warfare: hold territory and attack the enemy's strongest point . While the desert is seen by many as a hostile environment that "distances and isolates [VPOs] from major population centers and force them to disperse rather than concentrate their forces" , it can also provide a resource to strike anywhere, anytime, and without apparent logic. Focusing on 389 violent events in which nine Al-Qaeda-affiliated groups have been involved, we highlight specific spatial patterns that emerge from a longitudinal analysis of events over a tenyear period starting in 2004. Due to the transnational nature of conflict, we ascertain the countervailing transaction costs that borders represent, notably by testing whether national borders limit the displacement of Islamist groups or serve as sanctuaries whence attacks are launched. The article proceeds as follows. The second section reviews the literature on the social and spatial organization of state and non-state organizations in West Africa, paying particular attention to the role of networks and national borders. The third section presents the data and explains how, using network analysis and geographical information systems, we structured them into networks and chronological events. The fourth section models the structural position of actors in conflict. The fifth section addresses the spatial patterns of Islamist groups and implications of the findings for theory, method, and practice. --- Previous research --- Conflicts and signed networks Greater access to geo-referenced data and the use of spatial statistical analysis has advanced the study of social and spatial patterns of armed groups over the past decade. While past analyses of wars were limited by a lack of reliable data, the proliferation of satellite and disaggregated data has spawned innovative approaches to investigating the onset and diffusion of political violence across time and space . The concomitant proliferation of political and economic predictors on which the spatial-analytical approach in geography can draw now includes factors as diverse as the nature of government, ethnic divisions, poverty, income, inequality, number and morale of troops, frequency of droughts, and endowment of natural resources . Some factors that may explain why groups resort to violence are also related to the structure of relationships that connect actors in conflict . Political violence is a relational process; so, individuals and organizations are all, to varying degrees, embedded in networks of alliances and conflicts that enable or restrain action. The increasing availability of disaggregated data, combined with recent conceptual and computational advances in network science, is reason to reevaluate the importance of social network analysis within the field of conflict studies. SNA is the study of individual actors, groups, organizations or countries, represented by the nodes of the network, and the relationships between these actors, represented by their links. As both a paradigm of social interactions based on graph theory and a method, SNA seeks to understand networks by mapping out the ties between the various nodes as they are rather than how they ought to be or are expected to be . SNA is particularly adept at capturing the complexity of conflict situations due to its ability to describe, represent, and model signed networks, i.e. networks that contain both positive and negative relations. Positive ties develop to overcome collective-action problems, enforce trust and ideology, coordinate activities at a distance, distribute resources, or disseminate ideas and decisions. Political alliances between states are typical of positive-tie networks. By contrast, negative ties develop among actors that dislike, avoid, or fight one another with various levels of intensity. For positive and negative ties, SNA can be used to study the structure and function of the network as a whole, and the role of each node in the group in relation to others. Maoz and colleagues, for example, have used a network approach to model the effect of political and economic interdependence on the evolution of inter-state conflicts over a century . Using the case of World War I, Flint et al. and Radil et al. have shown how alliances or rivalries between states could explain the diffusion of war on a global scale. Radil and Flint have applied the same approach at the African level. Recent studies have noted that networks with positive ties tend to be structured differently from those with negative ties . Networks based on friendship, alliance and collaboration are known for being denser and more clustered around actors that share similar values than networks containing negative ties, because individuals and organizations tend to have more friends than enemies . Positive-tie networks also convey more resources, ideas, and knowledge than negative-tie networks based on hatred, avoidance or conflict. As a result, many centrality measures based on the assumption that social networks serve as conduits for flows of information, advice, or influence, such as betweenness or closeness centrality, are unrealistic in the case of actors in conflict . For example, if the Algerian military is the common enemy of both AQIM and the Movement for Oneness and Jihad in West Africa , flows are unlikely to pass from AQIM to MUJAO through the Algerian military. Networks containing negative ties are also well known for having a low level of transitivity, a principle that assumes that two actors that share a connection to a third actor, are likely to be connected themselves. A growing literature in conflict studies and related social sciences suggests that, despite their differences, positive-and negative-tie networks should be analyzed simultaneously . One way to incorporate both allies and adversaries is to use structural balance theory, which argues that social relations are stable if they contain an even number of negative ties . Stable groups of three actors , for example, are theoretically stable if everyone likes everyone else, or if two actors are in conflict with a third party . Over time, unstable triads theoretically evolve towards stable triads, because instability creates tensions that can only be resolved by altering views, behaviors and alliances. Another approach to signed networks is to model the structural autonomy and constraints of actors. In a recent article, Smith et al. argue that an actor's political independence is constrained both by its potential to reach other actors' resources and by the structural position of allies and enemies. Being connected to a single ally that is free of threat considerably reduces the autonomy of actors in signed networks, while a diversified network of allies enhances autonomy. This article adopts a complementary approach. Instead of assuming that political violence is explained by attributes of the belligerents or by exogenous factors, we posit network structure to enable or constrain political violence. To do so, the first part of our analysis aims at representing how VPOs are connected to their allies and enemies. Using several centrality measures, we identify subclusters of actors within which conflict or cooperation is particularly developed, and highlight the main structural differences between positive-and negative-tie networks. Since enemies and allies are inextricably linked in real-life networks, the second analytical part of the article considers positive and negative ties simultaneously. Using spectral embedding techniques that place the nodes representing organizations at the position that best balances the "pull" of allies against the "push" of enemies, we model the balance between the relative effects of having allies and foes simultaneously. We take into account the fundamental asymmetric nature of conflicts and consider whether groups attack more or less than they are attacked. Combining signed and directed networks, we expect groups with similar allies and foes and similar aggression patterns to form clusters that concur with their structural position in the social network. --- Conflicts, borders and safe havens A growing literature suggests that national borders are not only potential sources of dispute between states; they also provide a safe haven for VPOs that compete with sovereign states . Borders open markets of opportunity for rebels and jihadists that exploit weak states and their lack of intraregional cooperation. Of the 59 terrorist groups designated by the U.S. Department of State in January 2014, 39 are thought to operate from a safe haven , many of them in border areas. In Asia, border sanctuaries are mainly found in Pakistan-and Indian-administered Kashmir, Pakistan's Federally Administered Tribal Areas, Pakistan's North Waziristan, and Baluchistan. In the Middle East, the Syrian and Iraqi borders are well-known safe havens to myriad armed groups . Sunni-dominated areas of the Syrian-Lebanon border are used as safe havens by Syrian opposition forces, whereas Shia-dominated areas are used by Hezbollah to launch attacks or enter Syria . In South America, the Colombia-Venezuela border and the Brazil-Paraguay-Argentina triangle have been linked to transnational groups . In Africa, the Great Lakes region and the Liberia-Sierra Leone borderlands have been used by rebel groups to challenge the sovereignty of states, while Somalia is well-known as a sanctuary for Al-Shabaab . How VPOs use borders in the Sahel-Sahara is a matter of scholarly debate. Some claim that terrorist groups such as AQIM have divided Africa into "zones", each led by an emir and that the movements of the most prominent emirs are primarily centered on certain regions . This approach explicitly deems sovereign state borders safe havens for traffickers, rebels and terrorists. Others contend that the territorial notion of safe haven was probably an inappropriate concept to grasp the spatiality of Trans-Saharan politically violent organizations ). While certain VPOs have repeatedly mounted attacks in the same area, this approach argues that attacks mostly seek to control strategic cities and lines of communication, and not to capture and hold territory. This principle explains why the aims of many Salafist groups are more socio-political than territorial: "All we want is the implementation of Sharia" reportedly said a member of the Ansar Dine group in Mali, "We are against independence" . This is reminiscent of pre-colonial polities that distinguished between ownership and control of land and where, as noted by Herbst , authority extended everywhere people had pledged obedience to the king. Daesh has adopted a similar strategy. It seeks to control a network of cities, roads, military bases and oil resources across Syria and Iraq and promotes the view that all true believers should be brought under a Caliphate, without necessarily holding a contiguous and fixed territorial entity . This article engages this controversy in light of the spatiality of VPOs and the effect of sovereign state borders on their movements. Do borders represent sanctuaries behind which VPOs wage turf battles over aspirational homelands? Or, as T.E. Lawrence posited a century ago, is desert warfare more like naval war in the sense that insurgents are mobile and relatively indifferent to the constraints imposed by their environment? We propose that the degree to which groups can move and challenge the territorial integrity of sovereign states is a function of the porosity of borders. From the beginning of the millennium until the French-led Opération Serval regained control of the main cities of Mali in 2013, intraregional cooperation remained weak and each state had its own border-management strategy . This uncoordinated response to the rise of VPOs in West Africa should have an observable effect on their mobility patterns across the region. More cross-border movement might be anticipated where borders are not heavily guarded and/or easy to cross due to informal arrangements with state authorities than where there is greater capacity to ensure border integrity through effective border patrols and law enforcement. --- Research design --- Social network analysis Our analysis relies on disaggregated data from the Armed Conflict Location and Event Dataset , which provides a comprehensive list of political events by country between 1997 and 2014 . The fifth version of the data was used to select 37 VPOs in the Sahel-Sahara region, their allies and their enemies, excluding non-identified Islamist and Libyan militias . The scope was limited to events with the following seven referents: Battleno change of territory; Battle -Non-state actor overtakes territory; Battle -Government regains territory; Riots and protests; Violence against civilians; and Remote violence. This produced a list of 3231 events involving 179 organizations and 27,791 fatalities. The ACLED dataset describes four groups in each incident: an attacker , a collaborator in the attack , a target , and a potentially assisting group that may also be a secondary target . This data is used to build a social network in which the nodes are groups, with positively weighted directed ties between groups that interacted and negatively weighted directed ties between attacker and target . For example, on January 12, 2014, clashes between French troops and Malian troops on the one hand, and Ansar Dine and MUJAO on the other hand, claimed 11 lives, including Islamist leader Abdel Krim, and 60 injured . Incidents are aggregated so that the ties between any pair of groups reflect all of their interactions. There can be both positive and negative ties, and in both directions, between the same two groups. Directions are important because they are surrogates for intentionality: a group on the offensive makes a conscious decision to attack while the defender has no choice, and other groups must decide whether to join in or not. These decisions reflect a calculus of advantage or ideological alignment. The resulting graph is analyzed in two steps. First, we map the networks containing negative and positive ties separately and analyze the most prominent actors using several centrality measures. Because negative-tie networks do not serve as conduits for flows of information, advice, or influence, we use degree centrality, which simply refers to the standardized number of ties each node has, and eigenvector centrality, which refers to the number of nodes adjacent to a given node, weighted by centrality, and indicate whether nodes are connected to other well-connected nodes. For our positive-tie network, we use eigenvector centrality and betweenness centrality, which measures the number of shortest paths from all nodes to all others that pass through that node . Second, we combine both positive and negative ties into a single network, and embed this network in a geometric space in such a way that the distance between each pair of points accurately reflects the balance between the 'pull' from collaborating groups and the 'push' from aggression between them. These distances are globally integrated by considering not only immediate neighbors1 , but neighbors of neighbors and, in fact, the structure of the entire graph. It is this integration that makes the process challenging: positive relationships are naturally transitive but negative relationships are not . Technically, the adjacency matrices that describe positive and negative ties are combined into a matrix, called a Laplacian, that combines both kinds of ties and normalizes the representation so that wellconnected nodes are central and poorly connected nodes peripheral . This Laplacian matrix is transformed to discover the directions in which the graph varies the most and these are used as axes for creating an embedded graph. In this representation, position and distance are meaningful. Sets of 'bad actors' such as VPOs and 'good actors' such as governmental forces and civil society tend to form polar opposites in some dimension of the representation. Since proximity represents similaritycommonly known as an alliancedistance tends to represent opposition. --- Spatial patterns To understand the spatial strategies of VPOs, we limit the scope to nine Trans-Saharan organizations that subscribe to an Islamist ideology: Al Qaeda, Ansar Dine, AQIM, the Armed Islamic Group , Al Mourabitoune, the Free Salafist Group , the Salafist Group for Preaching and Combat , MUJAO, and Those Who Signed in Blood. Affiliated with al Qaeda, these Islamist groups share a common historical and ideological background and form several components of a single, flexible network, rather than independent entities. As reminded by Hagen , "AQIM overlaps with a number of nominally independent and 'locallyfocused' groups, such as Ansar al Dine and MUJAO. These groups are part of the larger AQ family and cannot be separated from AQ and AQIM". Mergers, name changes and splits are common. For example, GSPCa splinter group of GIA of Algeriarebranded itself as AQIM in 2007. Some of its members broke off in 2011 to form MUJAO while others formed Al Moulathamoun and Al Mouakaoune Biddam . In 2013, MUJAO merged with Al Moulathamoun to form Al Mourabitoune, which, in 2015, was renamed Al Qaeda in West Africa . Those groups frequently exchange information, funding, hostages, and conduct joint operations since several of their leaders have historically been members of AQIM's leadership network and have developed multiple allegiances across organizations . Our sample does not include Boko Haram; its activities are almost exclusively located in the Sahelian part of West Africa and its use of political violence differs from other Islamist organizations in the region . While AQIM has urged local emirs to refrain from violence against civilians and encouraged them to gain the hearts of the people, Boko Haram has, since its leader was killed in 2009, used indiscriminate violence as its principal political instrument . Using a Geographical Information System , our first step is to map all violent events in which these Islamist groups were involved over the last 10 years. The year 2004 is the starting point of the development of VPOs that had hitherto been almost exclusively located in Algeria . These groups, their allies and their enemies are responsible for 389 violent events totaling 1,434 fatalities through 2014. Our next step is to develop two hypothetical scenarios to distinguish distinct spatial patterns. The 'mobility' scenario assumes violence follows a linear chain of events: groups move from one location to the next, possibly across borders, without returning to their original location. This would reflect the strategy of a group under intense pressure from security forces, or, alternatively, of a group that has mastered movement in an arid environment. By contrast, the 'sanctuary' scenario supposes a territorial turf whence groups operate across borders and a clear origin of flows. Once the location of each event is known, our third step is to connect violent events chronologically through hypothetical lines and verify if the general spatial pattern of the attacks corresponds to one of the two scenarios described above: the 'mobility' scenario where groups move freely across borders, or the 'sanctuary' scenario where groups use a particular region as a rear base. Since the ACLED database does not contains information about the movements of Islamist groups, we use dotted lines to indicate that spatial patterns based on the location of violent events do not necessarily correspond to actual physical movement between places, but rather to a longitudinal series of events. --- A social network analysis of political violence --- Negative-and positive-tie networks We start with a graph that represents each organization as a node that is connected to those actors with which it is in conflict. The size of the nodes in Figure 1 is proportional to the number of ties . Three main clusters emerge: the Nigerian cluster that is polarized by Boko Haram; the Trans-Saharan cluster that is composed of groups affiliated with Al Qaeda such as GSPC and AQIM and their enemies; and the Libyan cluster that is composed of myriad Islamist brigades and progovernment forces. With a density of only 0.023, the network is very sparse, which is typical of networks that are made up exclusively of negative ties: the number of enemies a group can have is often more limited than the number of potential allies . The network also has a low level of transitivity: in only 1.2% of the triads enemies of enemies are in fact enemies, while in most cases , enemies of enemies are friends. Finally, organizations with adverse attributes tend to be in conflict with one other, a tendency known as heterophily . This can be tested using the E/I index, which calculates the difference between external and internal ties for each group of actors , divided by the total number of ties. The E/I index for the network is positive and statistically significant , which confirms that VPOs clash with organizations that do not belong to the same category. At the level of the organization, the network is composed of few highly central organizations . That makes sense since being in conflict with many adversaries simultaneously is widely regarded as a liability rather than as an asset . Negative relationships adversely affect the outcomes of VPOs' military operations, reduce their ability to coordinate activities across the region, and limit their ability to cooperate to achieve their political or religious goals. Among politically violent organizations, AQIM has the highest score in degree and eigenvector centrality, which indicates that it has the greatest number of enemies and is connected to other actors that also have many enemies, such as the military and police forces of Algeria. MUJAO, GSPC and GIA also occupy a prominent structural position due to their conflicts with civilians, and armed forces in several countries. Other prominent actors include Boko Haram, which stands out for being connected to many other actors who themselves have few connections to one other, and some Libyan groups such as Ansar al-Sharia and Libya Shield Brigade. The structure of the network of enemies contrasts strongly with the one showing how organizations involved in violent events have collaborated across the region. As depicted in Figure 2, the positive-tie network is divided into three main unconnected groups of allies, one triad connecting an unidentified armed group to Boko Haram and Ansaru, and three dyads. The main cluster on the left is structured around North and West African military and police forces and their civilian allies, which are represented in red and yellow respectively. This cluster is indirectly connected to some of the main Islamist groups in the region, which are represented in green, through the secessionist movement MNLA. MNLA was allied with Ansar Dine in the first weeks of the Malian conflict before switching sides and fighting alongside the French-led military forces in 2013. The two other clusters are related to the Libyan conflict. One is structured around the armed forces of Libya and their pro-government brigades and battalions, the other around Islamist groups and ethnic and communal militias. Each cluster has a chain-like structure in which organizations are rather distant from one another. The Algerian Private Security Forces, for example, are eight steps away from Al Mourabitoune. The long path-length distance, low density and low clustering coefficient of the network are typical of a structure that is not organized around groups of tightly connected actors. This suggests that most governmental forces and VPOs tend to build bilateral or trilateral alliances rather than broad coalitions across the region. The graph also highlights the lack of regional cooperation between government forces that face similar threats: there is no reported tie between the military forces of Libya and Algeria, or between the military forces of Cameroon and Nigeria. Figure 2: Positive ties between organizations involved in violent events, 1997-2014 Notes: green nodes refer to Islamist groups, red to government forces, yellow to civilians, and blue to other actors. Military and police forces have the highest eigenvector and betweenness centrality, followed by Ansar al-Sharia and the Shura Council of Benghazi Revolutionaries , both of which hail from Libya . Generally speaking, betweenness centrality scoresthat refer to the propensity to bridge clustersare very low, even for top-scoring nodes, which suggests that the networks contain few exceptional brokers. Only the French military forces play a role in bridging several African armed forces that would otherwise not be connected, hence their high betweenness centrality. Once again, the isolation of Boko Haram in Nigeria contrasts sharply with the network of alliances among other Sahelo-Saharan and Libyan groups. Note: Scores are indicated between brackets. --- Spectral embedding Now, we compute the spectral embedding of the social networks derived from the ACLED data. Initially, for the sake of simplicity, we disregard the direction of the ties. The embeddings are shown in Figure 3. Negative ties resulting from recorded attacks are shown in red and positive ties resulting from alliances, or at least common purpose, are shown in green. The general structure is of a group of opposing poles representing groups whose primary relationship is that they attack or are attacked by groups at the other pole. The graph clearly shows how 'bad' actors such as Islamist and Jihadist groups are grouped opposite 'good' actors, both violent and nonviolent. The contrast is particularly evident for Boko Haram, and its opposition to governmental forces and civilians from Nigeria and Cameroon, as well as for GIA-GSPC-AQIM, and its opposition to Algerian armed forces and civilians. The graph also shows that the attack patterns of GIA, GSPC and AQMI differ significantly from those of Ansar Dine, MUJAO and Al Mourabitoune, which are located much closer to the center of Figure 3. Any measure that considers a group in isolation is unable to distinguish VPOs from military or police organizations because both have similar patterns of interaction. We, therefore, compute measures of outward and inward aggression based not on the number of such incidents but on the length of the relevant ties in the embeddings. A group's position in the embedding reflects its relationships with all of the groups with which it interacts, and, therefore, the length of the embedded ties is more revealing than simply the number of attacks. For example, the distance of a group from the center of the embedding reflects not only how many other groups attack it but also the extent to which its enemies are similar to one another . Thus a long red tie measures not only the existence and frequency of attacks, but also their strategic intensity. On Figure 4, groups are plotted at the same positions as in the spectral embedding presented in Figure 3 to denote "levels of aggression". They measure the outgoing aggression of each group and the incoming aggression to which it is subjected. They are color-coded: red means a group generates more aggression than it receives; orange means that the group generates some outgoing aggression; and green means that there is no outgoing aggression . --- Figure 4: Spectral embedding showing levels of aggression The vicinity of groups presented in Figure 4 allows us to distinguish VPOs from national defense forces . In other words, most of the polar opposites consist of 'bad actors' on one side and 'good actors' on the other, and they are structurally distinct. 'Bad' aggressive actors such as AQIM or Boko Haram tend to be in clusters of net aggressors, or isolated; 'good' aggressive actors such as militaries tend to be in clusters with orange and green groups. Neutral actors such as the International Committee of the Red Cross tend to fall in the middle and green. Victims are also green but tend to be located near their champions. Northern Nigeria and Libya are particularly interesting as they involve many VPOs with strong structural constraints. From the literature we would expect Northern Nigeria, where Boko Haram is particularly dominant, to have more of a dual structure than Libya, where myriad of violent groups compete for the control of the state and oil resources . We find that our intuition was correct as Figures 5 and6 show. Spectral embedding showing conflicts and cooperation for 37 organizations in Northern Nigeria clearly confirms that Boko Haram is in conflict with virtually everyone, a situation comparable to that of ISIS in the Middle East, which opposes all governments and non-state actorsincluding Al Qaedain the region. Figure 5: Spectral embedding showing positive Figure 6: Spectral embedding showing and negative ties for 37 organization in positive and negative ties for 30 Northern Nigeria organizations in Libya Note: for the sake of clarity, Ansaru is not shown. In Libya, spectral embedding conducted on 30 organizations highlights the ongoing conflict between pro-Islamist groups and pro-government forces . Islamist groups, on the left of the graph, are composed of Islamist militias such as Libya Dawn and Libya Shield, and of Jihadist groups close to Al Qaeda such as the Revolutionaries Shura Council , a coalition that includes Ansar al-Sharia, the 17 February Brigade, and the Rafallah Sehati Brigade. These groups, based in Tripoli and in Benghazi, all oppose the Libyan army, as indicated by several long red ties. Among pro-government forces, on the right, are anti-Islamist militias such as the Zintan Militia, the Al-Sawaiq Battalion and the Al Qaqa Brigade. Civilians and journalists are located near the internationally recognized authorities of Libya. --- Spatial analysis of mobility patterns This section examines the spatiality of select Islamist groups that have developed attack patterns across the Sahel-Sahara region. For strategic and policy purposes, we are particularly interested in whether state border strategies and multinational military missions have had a measurable effect on the transborder movement of Islamist groups. --- Changing mobility patterns The analysis that follows reveals no evidence of a 'sanctuary' pattern in which Islamist groups make systematic use of a particular border area. However, Table 3 reveals that the movement of Islamist groups changed completely between 2004 and 2014: while the first seven years were marked by an apparent unpredictability of events across time and space, the last three years were characterized by a concentration of events, due to the outbreak of the Malian conflict and the strategies adopted by some states to control their borders. This shift occurred in a political environment where the number of violent incidents and victims related to Islamist groups in Sub-Saharan Africa has been on the rise . While only 30 events totaling 201 victims were reported between 2004 and 2008, there were 359 events and 1233 victims between 2009 and 2014. The intensification of attacks significantly reduced the average frequency between violent incidents, from an average of 44.8 days in 2008 to 7.5 days in 2014. The region has always been characterized by a high level of transborder activity. Figure 7 confirms that, until 2011, Islamist groups travelled extensively across borders and, in many regions of Mali, Mauritania, Algeria and Niger, without much risk of being apprehended. After Algeria expelled them, they were tolerated by the Malian government of President Amadou Toumani Touré , which sought to capitalize on divisions within Tuareg society and on a withdrawal of the state to administer the northern part of the country. Successive events repeatedly occurred hundreds or thousands of kilometers apart, in different countries, and irregularly, from Algeria to Mauritania, the Mauritanian-Malian border, and Niger. In 2005 and 2006, the average distance between two events exceeded 500 km, which is impressive given the harsh terrain and lack of road infrastructure, in particular in the Sahara. One of the best known movements of this period is also the one that marked the beginning of the Saharan expansion of what would become AQIM. Between 21 February and 11 April 2003, 32 European tourists were kidnapped in the region between Illizi and Amguid in Algeria by Abderazak el-Para and Abdelhamid Abu Zeid , two militants of GSPC. As Algerian security forces gave chase, the terrorists and hostages initially journeyed of over 3000 km to northern Mali. After having spent several months establishing alliances with leaders of local nomadic tribes, they moved to Niger through the plains of Azawagh, Aïr Mountains and the Ténéré desert, and ended up in the mountainous area of Tibesti in Chad where they were killed or captured, a second journey of over 2500 km through some of the most inhospitable environment on the planet . In 2011, Mauritania and Algeria undertook a series of joint counter-terrorism operations aimed at AQIM's military bases. Such an attack took place in the Wagadu forest on the border between Mauritania and Mali in June. The central intelligence cell created to facilitate co-ordination between Saharan and Sahelian countries, known as the Combined Operational General Staff Committee , first met in Bamako in April 2011. Nonetheless, the level of regional cooperation remained low because Mali was not trusted by its neighbors, which accused it of colluding with Islamist groups. Henceforth, Mauritania and Algeria would conduct military operations in Mali when they deemed their interests to be threatened by the activities of transnational groups. The chronological succession of attacks by AQIM in 2011 shows a high intensity and percentage of cross-border movements. For example, AQIM claimed responsibility for a bomb attack in Bamako, the capital of Mali, on 5 January, followed by a hostage taking in Niamey, Niger three days later. On February 1, these attacks were followed by an AQIM car bomb in the Mauritanian town of Adel Bagrou, the abduction of an Italian tourist in Djanet, Algeria, a day later, and the killing of a Mauritanian policeman by two members of AQIM in the region of Legsseiba near the north bank of the River Senegal on February 3. The year 2012 contrasts sharply with the period 2004-2011 because most events transpired in Mali, and, to a lesser extent, Algeria. Following the fall of Col. Muammar Gaddafi in Libya and President Amadou Toumani Touré a provisional alliance between Al Qaedaaffiliated groups and secessionists rebels of the MNLA launched a wide-ranging military offensive against the Malian army. Over a matter of weeks, all major cities of Northern Mali were seized, including Tessalit and Kidal in the Adrar des Ifoghas, where the offensive started, as well as Menaka, Timbuktu and Gao. New groups such as MUJOA and Ansar Dine were particularly active during this period and started to clash with their former Tuareg allies over the cities of the north of the country and main lines of communication. Our analysis shows that during this period the distance between violent events and borders is the more stable than the preceding period during which average distances to borders varied from 39 to 334 km. In 2013, the French-led Opération Serval reasserted control over Northern Mali. As French and Chadian troops progressed north, Islamist groups were driven from Kona, Douentza, Gao, Timbuktu, and were chased out of their stronghold of the Adrar of the Ifoghas. Operation Panthère, launched around Tessalit on 18 February 2013, successfully defeated them, possibly because the French and their allies adopted some of the principles of warfare that had made Islamists and rebels so successful in the region. Operation Panthère relied on a combination of airstrikes, artillery and ground combat operations conducted by the French, knowledge of the country provided by Tuareg guides, and Chadian desert warfare. Chadian troops and their highly mobile light trucks proved as effective in Mali as they have in the past 30 years in their own country. As in 2012, most events in 2013 took place in Mali and Algeria, along a south-west-north-east axis extending from Bamako in Mali to Tamanrasset in Algeria. Contrary to previous military engagements that targeted "one country, one crisis, and one theatre of operations", Opération Barkhane explicitly addresses the regional and cross-border dimension of terrorist activity throughout the region. The Operation relies on three ports in the Gulf of Guinea, two main airports in the Sahel, and a series of Saharan outposts located at the extreme periphery of Chad, Mali and Niger to disrupt cross-border trafficking routes and terrorist networks. Considering that Algeria and Libya are beyond the reach of any foreign armed forces and that the French military is stretched to the limit , for the time being Opération Barkhane is the most ambitious military initiative at the regional level. --- State border strategies Do borders not matter if they cannot offer sanctuary? On the contrary, our analysis suggests that borders do matter because countries have put in place management strategies that affect the spatial patterns of Islamist groups. Building on Arsenault and Bacon's distinction between government will and capability to fight foreign terrorist groups, four situations can be distinguished . States may have the military capacity to challenge transnational groups and choose to do so. In the region, Mauritania is probably the country most similar to this situation. Despite the small size of its armed forces, Mauritania took a number of strong military measures to control the flows of Islamist groups across its borders: develop mobile patrols, attack intruders systematically and establish partnerships with local tribes. As our analysis revealed, this firm attitude, combined with a national strategy for deradicalization , has occasioned a significant decrease of violent events since 2012. Some states may also be in a position to deny foreign fighters access to their territory but choose not to do so, for strategic reasons. Whether Algeria would have adopted this strategy is a matter of debate. On the one hand, having suffered from decades of political violence, Algeria is strongly committed to combating terrorism in the region and plays a major role in peace negotiations in Mali. During the Malian conflict, Algeria deployed tens of thousands of troops to secure its borders, which are probably the most heavily guarded in the region. On the other hand, Islamist groups would have been unlikely to emerge in Northern Mali if Algeria's borders had been hermetically sealed. Many of the aforementioned groups originally hail from Algeria or are affiliated with organizations based there, and there is strong evidence that Algerian borders are easily crossed by Islamist groups to get food and oil supplies through informal arrangements with state representatives . The third situation, where states may want to disrupt transnational groups without being able to project military power into borderlands, characterizes Niger. The 5,700 km border of Niger has long been poorly guarded due to lack of men and material. AQIM and other groups have capitalized on the situation either to take hostages in the region or to move to the south of Libya, where numerous Islamist groups have found favorable conditions . Finally, Mali exemplifies a lack of political will and ability to fight foreign Islamist groups. The gradual withdrawal of the state from the North of the country in the 2000s left Mali's borders unguarded and frequented by traffickers and militant groups. --- Conclusion The article examines the structure and spatial patterns of VPOs in the Sahel-Sahara, a region characterized by growing political instability over the last 20 years. Based on a novel approach that combines signed and directed graphs, our methodological contribution has been to highlight opposed groups and distinguish among several kinds of aggressors depending on their conflict patterns. In settings where groups form shifting alliances and oppositions, an approach that takes into account not only the local, pairwise relationships, but also the global patterns that emerge, is needed for situational awareness. Conventional social network analysis can represent positive ties, but not ties where direction matters, or where ties represent a negative association. Furthermore, these are not independent properties of a social network and so must be represented together. This article has illustrated the effectiveness of extending social network analysis to such settings. Conventional social network measures fail in these settings. For example, measures such as betweenness are inappropriate because negativity does 'flow' in the way that positivity is conceived, and centrality is not a crucial property when negativity separates nodes far from the center. From a theoretical perspective, the paper advances theory on the spatiality of Islamist groups by showing that sanctuary is immaterial to Saharan borders because many Islamist groups seek to control the movement of people and goods . The inability to garrison a sparsely populated region such as the Sahel-Saharawhich is the size of the United Statesmakes it difficult to hold territory. This situation is similar to the one adopted by Daesh between Syria and Iraq, and radically different from the territorial objective of such groups as Boko Haram in Africa, or the Taliban on the Afghanistan-Pakistan border, for which the defense of a delineated territory is paramount. Building on publicly available data, we started by mapping how 179 organizations involved in political violence were structurally connected through conflict and alliances. Our results show that the network that connects actors in conflict has a low density, a low level of transitivity, and contains few central actors, three typical features of negative-tie networks. AQIM is unequivocally the most connected organization, both in terms of the overall number of actors with which the group is in conflict, and the respective centrality of its enemies. In network terms, this is a liability. Divided into several clusters, the positive-tie network has a long path-length distance, low density and low clustering coefficient, a structure that suggests that most organizations tend to build limited alliances rather than broad coalitions across the region. We then combined the two networks and modeled the effect of having friends and foes simultaneously. Using the attack relationships, we also measured the level of outgoing and incoming aggression of each group. From this approach, five categories emerge. The first category includes neutral actors, represented in the middle of our graphs. The following categories include three kinds of groups that cluster together: victims, groups that are attacked more than they themselves attack, and groups that counter violence and thus attack more than they are attacked . The fifth category includes violent extremist groups that attack more than they are attacked, such as VPOs. Groups that are net attackers are indistinguishable at the level of individual behavior, but clearly separate into pro-and anti-violent extremism based on the groups to which they are close. This conclusion is in line with our original assumption that the propensity to use political violence concur with a group's position in the social network. The second part of the article mapped a series of 389 events related to nine major Islamist groups in the region. Spatial analysis suggests that violent events involving Islamist groups have followed different patterns depending on the period under consideration but reveals no evidence of a border 'sanctuary'. While violence was concentrated almost exclusively within Algeria until 2004, cross-border movement has since intensified, following the establishment of military bases by AQIM in Mali. This suggests a 'mobility' scenario similar to the Arab revolt of the 20 th century during which a highly mobile irregular force defeated the immobile and defensive Ottoman Turkish army. Our analysis suggests that until the French-led military offensive of 2013, military operations of trans-Saharan Islamist groups were "more like naval warfare than ordinary land operations, in their mobility, their ubiquity, their independence of bases and communications, their lack of ground features, of fixed directions, of fixed points" . More recently, Islamist groups have concentrated their operations in Northern Mali as well as Southern Algeria, leaving Mauritania, Niger and Chad relatively unscathed. Owing to the Malian conflict and to a series of state and international military initiatives, cross-border movement has been on the wane in some countries, which seems to validate our original assumption that Islamist groups concentrate on border segments that are less heavily guarded and/or where informal arrangements with border officials are possible. Our results have policy implications for governments and external forces involved in deterring politically violent organizations. First, unlike their adversaries, VPOs are socially and spatially connected across the regions; so, there is a need for collective security institutions that can help countries coordinate, build trust, and go beyond ad hoc engagements. In recent years, several 'Sahel' strategies have been initiated by organizations as diverse as the European Union , the United Nations , the Economic Community of West African States , the African Union , and the regional coordination framework G5 Sahel, to address governance, security and development in the region. Building institutional capacity around common interests is likely to pay off in a region that is largely devoid of collective security institutions. Precedent also suggests that states outside the region will continue to play a supporting rather than a lead role. In addition to supporting capacity-building efforts already underway, Western governments should be prepared to mount a comprehensive Whole-of-Government effort in support of local authorities that will minimize their local footprint while optimizing outcomes. From a military perspective, the fluidity of personal allegiances and mobility of actors across borders in the region calls for a mobile and flexible military response. Regional volatility notwithstanding, operations Serval and Barkhane suggest that desert insurgents are not impervious to external attack. As Western armies and their African allies become more mobile and flexible in their regional responses to political violence, desert insurgency proves to be a double-edged sword that can also work against those who know the terrain best.

This article examines the structure and spatial patterns of violent political organizations in the Sahel-Sahara, a region characterized by growing political instability over the last 20 years. Drawing on a public collection of disaggregated data, the article uses network science to represent alliances and conflicts of 179 organizations that were involved in violent events between 1997 and 2014. To this end, we combine two spectral embedding techniques that have previously been considered separately: one for directed graphs (relationships are asymmetric), and one for signed graphs (relationships are positive or negative). Our result show that groups that are net attackers are indistinguishable at the level of their individual behavior, but clearly separate into pro-and anti-political violence based on the groups to which they are close. The second part of the article maps a series of 389 events related to nine Trans-Saharan Islamist groups between 2004 and 2014. Spatial analysis suggests that cross-border movement has intensified following the establishment of military bases by AQIM in Mali but reveals no evidence of a border 'sanctuary'. Owing to the transnational nature of conflict, the article shows that national management strategies and foreign military interventions have profoundly affected the movement of Islamist groups.

INTRODUCTION In a global context, many persons with disabilities are not employed and when they are employed, they generally earn lower incomes . In response to this problem, the Indonesian government has tried to provide better employment services, but the results are still far from expectations. The results of research in Indonesia, particularly in Yogyakarta, reveal that public and private organizations in the regions cannot fulfill one percent of the work quota for persons with disabilities as stipulated in Government Regulation Number 43 of 1998 concerning Efforts to Improve the Social Welfare of Persons with Disabilities. This is due to the ineffectiveness of law enforcement, the amount of training provided but not in accordance with the potential for disabilities, and public awareness and concern about disability is still lacking . Therefore, many people with disabilities face problems such as difficulty in getting a job, discrimination, and inequality when getting a suitable job and justice during work. According to the 2018 National Socio-Economic Survey , 12.29% of Indonesian citizens are considered persons with disabilities, with 11.12% of them being in the productive age . In 2016-2018, the average income of people with disabilities in Indonesia is lower than non-disabled people . Age-friendly facilities in Indonesia are also limited and the existing facilities are not agefriendly so they do not support the mobility of persons with disabilities. This situation shows that the handling of disability issues in Indonesian employment services is urgent. Whereas policies related to persons with disabilities already exist, namely Law Number 8 of 2016. This law aims to protect the rights of countries with disabilities, among others, by setting a quota policy of 2% and 1% of total employment in state-owned and private companies. . However, law enforcement is considered ineffective . This study seeks to examine inclusive policies in Indonesia that lead to inequality of decent work for persons with disabilities in Indonesia. --- METHOD This study uses a qualitative approach. Secondary data is used to review various documents related to the employment of persons with disabilities. This study also uses regulations, reports, and articles. The information extracted from these documents is used to analyze inclusive policies related to decent work equality for persons with disabilities in Indonesia. --- RESULTS AND DISCUSSION --- Results Based on Law no. 4 of 1997 concerning persons with disabilities, it can be seen that Indonesia already has regulations for persons with disabilities, where this law is considered the highest law in the country at that time. However, even so, people with disabilities are currently still considered negative, namely as people with disabilities. Therefore, the government then ratified the Convention on the Rights of Persons with Disabilities , along with the issuance of Law no. 19 of 2011 and began to use the term Persons with Disabilities. This term is also used in the Law on Disabilities where persons with disabilities are defined as people who experience "long-term physical, mental, intellectual and sensory limitations", and experience limitations and difficulties in participating fully and effectively with other citizens based on equal rights . This law also regulates the distribution of employment services in Indonesia, where persons with disabilities are also entitled to employment, entrepreneurship, cooperatives, accessibility, public services, independent living, and free from discrimination . Despite the policy, there are growing concerns about employment for persons with disabilities. This situation is unavoidable, as many people with disabilities in Indonesia "have precarious jobs due to underemployment, and have few opportunities to advance their careers" . Persons with disabilities also mostly work in the informal sector with relatively lower take-home pay than non-disabled persons . Because disability issues are complex, there are various causes and challenges that can be seen in providing equal employment services for persons with disabilities. Such as employment services in Indonesia which are not yet comprehensive and affordable, the absence of unemployment insurance services for Indonesian workers and so on, which causes persons with disabilities to tend to be very vulnerable in poverty . The next challenge is how the current Law No. 8 of 2016 has not been fully implemented. This has resulted in continued employment problems for people with disabilities, such as difficulty in finding jobs and earning higher incomes, as evidenced by how people with disabilities in Indonesia tend to earn below the median income . The third challenge is the lack of public facilities for persons with disabilities. Accessibility is another issue, although some cities already have public facilities to accommodate persons with disabilities. According to a JICA survey, "public wheelchair corridors required by law" may not be available in Indonesia, and facilities for persons with disabilities are often useless because they do not conform to universal designs. The lack of adequate facilities also significantly hinders persons with disabilities from moving and working independently . Limited access to education for persons with disabilities is the fourth challenge. The main obstacle to education for persons with disabilities is the perceived low level of education, making it difficult for persons with disabilities to participate in the economy. The government also offers vocational training programs for people with disabilities, but people with disabilities prefer to look for other jobs because skills and qualifications that are unrelated and "uncompetitive, unless accompanied by advanced equipment and existing skills" make them tend to lag behind others . In addition, the lack of awareness of persons with disabilities and their employment rights is another challenge. This issue of awareness is not the last issue for equal employment services. However, the four challenges above, so far need to be considered because they are important factors in shaping the current situation of persons with disabilities and their work in Indonesia. If these challenges are not properly addressed, it is unlikely that disability will become a more comprehensive and decent work mainstream in employment services in Indonesia. --- Discussion Disability inclusive policies for the Indonesian government and society can be seen as a strategy to provide better employment services and build decent work for persons with disabilities. If we look closely, disability policies are considered to be underexplored in various policies and the results are not feasible to compare, for example in terms of poverty alleviation and approaches to other sectors, the results are still not feasible . However, disability inclusive policies are still important because they directly address core disability issues such as lack of awareness about disability and discrimination. Therefore, making an inclusive policy for disability is not a single strategy, it needs several comprehensive strategies that may have a wider target group, such as the poor and women. One of the keys is to include vulnerable groups, particularly persons with disabilities, in the agenda proposed by the employment service in Indonesia. On the other hand, the government also needs to issue regulations to ensure that Law no. 8 of 2016 is well implemented at the national level. The need for collaboration across ministries and different levels in the government hierarchy, as well as creating relationships between actors and the poor, is also one of the key success factors in creating better employment services for people with disabilities . If you look at the policies of the South African government, it can be seen that they carry out policies that emphasize the empowerment of marginalized communities, where exclusion is not only related to poverty but also race, gender and disability, but also contributes to inclusive development. By involving low-income and marginalized groups in this process and preventing their participation from being marginalized, we can reduce the risk of low product quality. It also supports community ownership, which is often critical to the success of inclusive policies . Nor is Norway a policymaker in the form of the Asker Welfare Lab at Asker which is a new concept of citizen-centred service delivery, with all relevant municipal services investing in their well-being with external partners. This laboratory has an investment spirit and treats residents as co-investors. The aim is to improve the living standards of vulnerable communities, thereby improving the quality of life of each individual and member of the program family. Asker Welfare Lab currently focuses on three specific target groups. Families with children suffering from "vulnerable living conditions", vulnerable youth aged 17 to 25 years, and families with children with disabilities . Then on the economic side, economic growth is also considered very important for the welfare of persons with disabilities, because it provides resources that help create conditions for more inclusive growth . The OECD describes inclusive growth as "economic growth that creates opportunities in all sections of the population and distributes the dividends of increasing wealth, both financial and non-monetary, equitably to society as a whole." Transportation systems also help reduce social exclusion by increasing access to private employment, education, health care, and social networks. Wide public transport coverage is a prerequisite for good accessibility, but in reality, coverage and access are not always related due to low frequency, low station density, and inadequate network. Therefore, it is very important to identify the need for accessibility restrictions for vulnerable groups. Those with low incomes also tend to experience limited transportation options, poor quality of transport services, and travel in poor conditions . This creates a "poverty trap". Other factors, such as age and disability, can also limit access to activities and services. In functional urban areas, more effective and reliable public transport infrastructure helps improve labor market performance of minority groups living in poorly connected urban areas . In addition, an inclusive entrepreneurship policy is also needed to ensure that everyone has the same opportunity to start and run their own business. This policy seeks to support people from social groups who are underrepresented in entrepreneurship or disadvantaged in the labor market . Supporting youth especially unemployed disabled people with targeted interventions could be the next solution. Many young people need little support to find work, those without a high school education and those with health problems or disabilities need more intensive assistance. Skills are needed to get a decent job. Social skills have also been shown to be malleable through adolescence and early adulthood, and have a profound impact on life outcomes, labor market engagement and income, and family stability. And indeed, intensive programs combining training with accommodation, mentoring and social support have been shown to have positive long-term effects on labor market participation, income, and reduced activity . Careful planning and strategies are needed, such as providing adequate facilities, creating an inclusive curriculum, designing teaching methods that improve practical skills and encourage people with disabilities to become more confident as a part of the community. The inclusiveness of all population groups, not just women as a homogeneous group, can now become the core of policy making. Its goals and objectives are intended to be universally applicable to all countries, and to all population groups within countries. Some specific goals and targets are explicitly targeted at specific groups, such as SDG 8.8 target on labor rights for migrant workers, or SDG 11.2 target on access to public transportation for women, children, persons with disabilities and the elderly. Social accountability also plays a key role as it ensures that everyone's voice is heard. It is also recognized that the role of citizens in policy-making has changed the relationship between government and citizens and is key for governments to increase citizen trust. For example, the existence of mechanisms such as free, fair and transparent elections, a functioning party system, access to public information and the involvement of various stakeholders in policy design, and service delivery and more Importantly, policy evaluation is the key to holding governments to account. In addition, access to justice and Legal empowerment is also one of the most important to provide awareness and tools to the public to participate more effectively in open government and consultation initiatives, but also shed light on corrupt practices and promote legal and regulatory protection Lastly, the role of media and journalism, by acting as supervisors and as a means of providing information can also be described as a key to accountability to ensure that various individuals regardless of race, color, gender, language, religion, political or other opinion, origin, disability, or sexual orientation can have access to timely information. and accurate without discrimination. Through this inclusive policy strategy, it is hoped that employment services in Indonesia will be improved again, including in the case that people with disabilities are expected to have decent jobs. The process of achieving equality and inclusion also requires the participation of everyone, and the results are likely to be visible after a few years. However, mainstreaming needs to be considered positively as an approach to employment services. --- CONCLUSION From the results of the study, it can be seen that employment equality for persons with disabilities in Indonesia is still lacking. This is triggered by weak law enforcement, poor employment services, and minimal supporting facilities at work. The availability of inclusive policies related to employment is a strategy to provide equitable services for persons with disabilities. For this reason, it is necessary to have a derivative policy from Law no. 8 of 2016 so that the legal basis for service implementation becomes clear. A., Nuryakin, C., Muchtar, P. A., Bella, A., & Rizal, H. . --- REFERENCE Mapping Persons with Disabilities in Indonesia Labor Market. Economics and Finance in Indonesia,63. https://doi.org/10.7454/efi.v63i2.572 Hamada, N. . Challenge to improve the public employment services in Indonesia-

The many problems experienced by persons with disabilities such as difficulty in getting a job, discrimination, and inequality when getting a suitable job and fairness during work indicate that the same service for all citizens has not been fully felt. This is also due to the fact that policy studies that are inclusive of persons with disabilities have not yet been fully implemented. This study uses qualitative research methods and then describes the results of the research descriptively. The final result of this research is a strategy to provide equality for persons with disabilities in employment services.

Introduction Social networks are an important source of credit, insurance, information, advice, and other economic and non-economic benefits and often substitute for limited formal institutions.1 But networks are not designed: they are the product of many decisions. In particular, as formal markets expand, the incentives to maintain or develop new relationships change. This could affect networks in unanticipated ways, potentially affecting even those who do not directly benefit from this expansion . In this paper, we study how the introduction of formal lending institutions changes social networks, both empirically and theoretically. In our first empirical setting, we analyze how the introduction of microfinance affects network relationships in rural communities. We show that MF entry leads to a general shrinkage of the network, even among those whose characteristics make them very unlikely to be borrowing from the microfinance institution . In fact, it is they who, despite being prima facie uninvolved with microcredit, appear to be the most affected, losing a considerable number of relationships among themselves. Because existing models of network formation struggle to rationalize these patterns, we develop a new model that can explain these findings. Our model highlights spillovers stemming from the decision to socialize or not. We subsequently replicate these surprising findings in a second, independent empirical setting from a randomized controlled trial offering microfinance to urban communities, demonstrating both the robustness of these findings and the fact that the loss in links persists even after microfinance is no longer available to these communities. The challenge in ascertaining whether formal institutions change informal social structures is that it requires detailed data on networks of informal relationships, together with exogenous variation in access to formal institutions. Our two empirical contexts satisfy both requirements. First, we analyze the introduction of MF in rural Karnataka, India using detailed network panel data that we collected over six years in 75 villages. These villages were selected in 2006, prior to the first survey wave, when none of them had access to microfinance, but a microfinance institution, Bharatha Swamukti Samsthe was planning to start operating in all of them. Between 2007 and 2010, BSS entered 43 of these 75 villages, which we call MF villages. However, a series of external crises halted BSS's expansion and the remaining 32 villages were not exposed to BSS prior to our Wave 2 survey, collected in 2012. We call these non-MF villages. We take advantage of this variation, along with our extremely detailed network data from the two waves to estimate the impact of MF on village network structure, using a difference-indifference strategy. Second, we replicate and extend the Karnataka findings, leveraging an RCT conducted in 104 neighborhoods in Hyderabad, India, using cross-sectional survey data that we collected . In the RCT, entry by an MFI was randomized to half of the study neighborhoods. Control areas began receiving access to Spandana two years later. But in 2010 Spandana suddenly ceased all operations, due to the same crisis that halted BSS expansion. We surveyed all households for a final time six years after initial entry when they had little or no access to microcredit. However, the households in the early entry neighborhoods had been exposed for twice as long when microcredit was shut down and had received much larger loans. We therefore estimate the impact of this differential access to microcredit using data we collected in this survey about each respondent's network relationships, as described below. The advantage of the Karnataka setting is that we have high-quality network data. We know details of link patterns between households as well as the nature of the link . Furthermore, it is a panel and so allows us to condition on pre-period network structure. However, the setting does not involve an RCT and therefore our identification relies on the difference-in-difference assumption being valid. The Hyderabad dataset avoids this issue, since initial entry was randomized: Treatment neighborhoods had exogenously more cumulative access to microfinance than Control neighborhoods. It also serves as a validation because the hypotheses we test in this data come from the results of the Karnataka analysis, which were generated before we looked at the network data in Hyderabad. Finally, because the survey was fielded 6 years after initial entry and 4 years after the late-entry group received access to MF, this illustrates the extent to which these kinds of effects can be durable.2 However, in Hyderabad we only have one cross-section of network information, and we only have partial network data. To supplement it, we collected "aggregated relational data" and use the new methodology from Breza et al. to estimate features of the network. Our ARD survey asks each respondent to list their network relationships and to indicate how many of those individuals have a series of traits, . Breza et al. and Breza, Chandrasekhar, McCormick, and Pan have shown that these responses contain sufficient information to identify the parameters of a network formation model which can then be used to estimate the key characteristics of the neighborhood network that we need for our analysis. Breza et al. and Breza, Chandrasekhar, McCormick, and Pan show that this method is an effective way of identifying effects on networks, comparable to the case where the researcher has full network data. The impact of microfinance on network connections can potentially go in either direction. As a source of formal credit to poor, underbanked households, microfinance may reduce their dependence on social networks for informal credit and insurance. Moreover, the required weekly repayment structure of microloans may reduce borrowers' liquidity and limit their capacity to lend small sums to their friends . On the other hand, if households re-lend a part of their formal loans, microfinance could crowd in informal financial relationships. 3In both of our datasets we find that the introduction of microfinance crowds out social network relationships. The probability of a link between any two households declines by 11% in a MF village compared to a non-MF village in the Karnataka sample. This is robust to controlling for a rich array of baseline variables. We estimate an even larger effect in the Hyderabad RCT -a 22% decline . We then investigate how the changes in networks are distributed across two types of households: those who are likely to take up microfinance loans and those who are not. All of the channels described above suggest that microfinance might affect a borrower's willingness to maintain friendships, including with those who do not take up microfinance. However, prima facie , one would not expect effects on pairs of households that are both unlikely to take up microfinance. If anything, one would have expected links between these households to be strengthened in microfinance villages, since they might be losing access to the households that get microfinance but still have needs to borrow and lend. To look at this question empirically, we need to be able to compare those who are more or less likely to take up microfinance in MF villages/neighborhoods to those in a non-MF village who would have been comparably likely to take up microfinance had it been available in their village/neighborhood. To this end, we use a random forest model to classify households in all villages into two groups based on whether they would have a high or low likelihood of joining microfinance if it were offered in their village. We begin with the Karnataka panel by looking at the difference between MF and non-MF villages in the probability that two Ls who were linked in Wave 1 continue to be linked in Wave 2. Because L households have a low propensity to borrow from microfinance, they are unlikely to experience any direct impact. The surprising result is that LL links decline as much as LH links and more than HH links in MF villages relative to non-MF. An LL link that exists in Wave 1 in a MF village is 5.8pp less likely to exist in Wave 2 compared to a similar link in a non-MF village; this decline is, if anything, greater than the decline in HH links . Similarly, LL links are less likely to form in MF villages, again, even less so than HH links. The cross-sectional data from the Hyderabad RCT delivers consistent results. Treated MF neighborhoods have 0.6pp fewer LL links than control neighborhoods , and there is no evidence of a greater decline in LH or HH links. We then examine the evolution of links that form triangles. In the Karnataka sample, we find that it is the LLL triangles that are most likely to disappear in MF villages compared to non-MF villages. In MF villages, LLL triangles are 7.8pp more likely to have at least one link broken than in non-MF villages, more than any other type. The difference is greatest and most significant between LLL and HHH, but even LHH are less likely to break than LLL . LLL triangles are also more likely to entirely disappear in MF villages, and the difference from all of the other types of triangles is significant. In the Hyderabad data, we also find that we are significantly less likely to observe a LLL triangle in treatment than control villages. Thus, we observe loss of links even among people least likely to be involved in microfinance and in parts of the network that do not directly involve a connection with Hs. These findings suggest that models of purely local externalities are unlikely to be able to explain our results. Strikingly, even though the direct impact of microfinance is likely to be on financial links, the same patterns also emerge when we analyze information links. This suggests that there is contagion from one type of relationship to others. These types of spillovers, both across types of links and across types of households, are prima facie inconsistent with models of network formation where the decision to form a link only depends on the payoff to the two parties forming the link and these payoffs only depend on the characteristics of the parties involved in the link and no one else. We briefly sketch a set of these models that are standard in the literature in Online Appendix D: these include mutual consent models of directed search, stickiness in dropping or forming links, and local payoff externalities. 4A potential explanation for why preexisting LL links also drop in large numbers comes from a model of network formation with local payoff externalities. Many models of network formation focus on payoff externalities ; Mele .Specifically, an LL link may be partly sustained by its shared connections to an H that was directly impacted by microfinance. However, the result that LLL triangles are at least as likely to be affected as triangles involving Hs rules this out as a sole explanation. We develop a new model of network formation that can explain why links between the Ls might break at least as much as other links. The model we build comes from a simple idea. In the model, old relationships are maintained and new ones are formed when people socialize in an "undirected" way. A stylized interpretation is that people show up at the town square, or a local tea shop, to "hang out" and socialize. Seeing their current friends keeps those relationships intact, and meeting new people sometimes results in new relationships. People who do not show up at the town square lose old relationships and form fewer new ones. We describe this as a model of undirected search. This gives rise to a distinct network-level externality, because the returns to socializing depend on who else is socializing. Holding fixed the valuation of a certain link or groups of links, the fact that, in equilibrium, others are not searching can have global effects on network density and topological structure. For example, L types value HL links, and thus care about how H types socialize. Therefore, if microfinance changes the socialization of H types, that changes incentives for L types to socialize, which in turn affects the incidence of LL links. Specifically, access to microcredit might reduce both the demand and supply of informal loans by H types, but the Hs becoming less willing to lend can have a larger negative impact on Ls than on Hs, which leads to less socializing by Ls. As Ls socialize less there is a larger relative drop in LL links. A simple extension of the model to account for the formation of triads generates similar results for LLL relationships. This model matches the patterns we observe in the data, in particular the spillovers to the relationships between L types. It also predicts that there should be spillovers across different types of relationships, since it is the same town square where people also form other relationships such as advice relationships. Given that we see network connections shrinking, a natural question is whether we see changes in downstream outcomes, such as borrowing or the volatility of consumption. Indeed, consistent with the disappearance of the LL links, we find in both settings that the L households, after the introduction of microfinance, borrow relatively less from informal sources in MF compared to non-MF villages. Finally, in the Hyderabad sample we can directly measure the impact of increased microfinance exposure on consumption smoothing for high-and low-borrowing propensity households. This is possible because we have detailed panel information on both income and consumption at the household level. We find that, in areas exposed to microfinance, households with high propensity to use microfinance see little change in their consumption smoothing compared to those in areas not exposed to microfinance. However, households with low propensity to use microfinance see a large and significant worsening of their consumption smoothing compared to those in areas not exposed to microfinance, which is consistent with the network and informal borrowing impacts. Our research on how exposure to formal financial institutions affects social and economic networks is related to some important recent and ongoing work. Feigenberg et al. find that participation in microcredit creates tighter social relationships among group members. Binzel, Field, and Pande and Comola and Prina In recent work, Heß, Jaimovich, and Schündeln also examine how policy interventions affect network structure but in the context of a community-driven development initiative . The initiative provided a very large disbursement-one half of annual per capita income-per household in each treatment village, and villagers had to collectively decide which projects to execute. Heß et al. collected a cross-section of network data in 2014 and, like us, document declines in network density and closure, which in their case are generated by political maneuvering and elite capture. A key difference between CDD and microcredit is that the injection of the former is massive and at the community level whereas micro-loans are both smaller in size and are only suitable for a small subset of the community; so the general equilibrium effects on network structure come from very different sources and for different reasons. 6 Our study contributes to and extends this line of inquiry. A main lesson from our paper is the presence of significant and widespread spillovers in network formation across types of people and types of relationships, which is indicative of a global network externality. We also use this evidence to build and argue for a new model of network formation that highlights the fact that social networks are not designed but result from the decentralized decisions of individuals. As our empirical results highlight, in such an environment, a shift in the incentives of one group of people to form links can have substantial effects on other parts of the network and groups that they ignore when choosing their own behavior. 7 The remainder of the paper is organized as follows. In Section 2, we describe the setting, network data collection, the classification of households into H and L types using a random forest algorithm, and sample statistics. Section 3 presents our empirical results. Motivated by the data, in Section 4 we develop a new dynamic model of network formation that is consistent with it and discuss why four standard models from the literature are inconsistent with the data. Section 5 presents impacts on informal borrowing and the capacity for households to smooth consumption. Section 6 concludes. --- Setting, Data and Sample Statistics 2.1. Setting. --- Karnataka . In 2006, the microfinance organization, BSS, provided us with a list of 75 villages in Karnataka in which they were planning to start lending operations. The villages were spread across 5 districts of the state of Karnataka in India. Prior to BSS's entry, these villages had minimal exposure to microfinance. how individuals' social networks change when randomly assigned to receive a savings account in Nepal. Their focus is on post-intervention expenditure spillovers, taking into account network change due to the exposure to the savings account. 6 Nonetheless, our model could still be useful in understanding the effects in such interventions. 7 See Jackson for background on inefficiencies in network formation. Here we see general, network-level externalities. Of course, this does not mean that microcredit should be discouraged, but only any welfare analysis needs to take into account the potential for spillovers. Six months prior to BSS's entry into any village, in 2006, we conducted a baseline survey in all 75 villages. This survey consisted of a village questionnaire, a full census that collected data on all households in the villages, and a detailed follow-up survey fielded to a subsample of adults. By the end of 2010, BSS had entered 43 villages that were not randomly assigned by us, but rather selected by the bank. We have anecdotal reasons to believe that the choice was not systematic: BSS planned to enter all of the villages but slowed down and ultimately stopped expanding during the Andhra Pradesh microcredit crisis for background on that crisis). --- Hyderabad . In 2006 Spandana -a large microfinance institution-randomly chose 52 of 104 neighborhoods in Hyderabad to enter. After two years, the remaining 52 neighborhoods received access in mid-2008. The short-and medium-run impacts of randomized access to microfinance in this setting are studied in Banerjee et al. . The AP microcredit crisis also impacted Spandana and its lending activities in Hyderabad. In 2010, all of the households in the Hyderabad sample faced simultaneous withdrawal of microcredit in response to an ordinance halting microcredit loans . A third round of data collection was done in 2012, with a sample of 5744 households. At the time of the 2012 data collection, the treatment neighborhoods had been exposed to microcredit for 6 years and the control neighborhoods had been exposed for 3.5 years . Network data was collected during this third round. The early treatment neighborhoods had greater microfinance access overall. Because microfinance borrowers typically receive larger loans each time they borrow, microcredit supply is increasing in the length of exposure. Banerjee et al. show that two years after the control group received access, households in treated neighborhoods still had 14% more contemporaneous microfinance borrowing and 43% more cumulative microfinance borrowing over the preceding three years . However, since nobody had access to microfinance at the time of our network survey, any changes to network structure that we pick up must be the result of the extra exposure to microcredit before it was shut down some two years before our survey. In other words, the effect persists despite there being no differences in contemporaneous participation in microcredit. --- Data. 2.2.1. Karnataka. To collect the network data, 8 we asked adults to name those with whom they interact in the course of daily activities. In Wave 1, collected in 2006, we have the full village census and network data from 46% of households per village. In Wave 2, collected in 2012, in addition to taking the full village census again, we have network data from 89.14% of the 16,476 households. This means that we have network data in Wave 1 on 70.8% of the links and in Wave 2 on 98.8% of the links when we build the undirected, unweighted graph that we study.9 For the network analysis, we concentrate on households that are present in both waves and only look at objects where we are able to discern in both waves whether the structure exists or does not exist. We have data about 12 different types of interactions for a given survey respondent: whose houses he or she visits, who visits his or her house, relatives they socialize with, non-relatives they socialize with, who gives him or her medical help, from whom he or she borrows money, to whom he or she lends money, from whom he or she borrows material goods , to whom he or she lends material goods, from whom he or she gets important advice, to whom he or she gives advice, with whom he or she goes to pray . Using these data, we first look at the financial network above) as well as the informational network from above). After demonstrating that links across both categories change in similar ways, we aggregate the network data as follows. We construct one network for each village, at the household level, where a link exists between households if any member of either household is linked to any other member of the other household in at least one of the 12 ways. We assume that individuals can communicate if they interact in any of the 12 ways, so this is the network of potential communications. The resulting objects are undirected, unweighted networks at the household level. We also asked, in both Wave 1 and Wave 2, for households to give us a list of all outstanding loans that they have taken, the sources of these loans and their terms. We use this to create a panel to study changes in borrowing patterns. In our analysis we look at all households who existed in Wave 1 . This involves those who remained and those who split. We match households who split in Wave 2 to their Wave 1 counterpart. 11% migrated out, though this is not differential by microfinance exposure, and 4.8% Wave 2 households in-migrated or split off from existing households , again not differential by microfinance exposure. 10 2.2.2. Hyderabad. The Hyderabad analysis draws on three waves of data. These data are also utilized in Banerjee et al. and Banerjee et al. . The first round of data collection was conducted in late 2007 -early 2008, 15-18 months after microfinance was made available in the treatment group. Following this first wave, the control group also received access to microfinance in May 2008. A second round of data collection was conducted in mid-2010 to examine longer-term impacts of access to microfinance; coincidentally, this wave took place just before the AP Crisis, mentioned above. Finally, in 2012, approximately two years after the AP Crisis, a third wave of data collection took place. All three waves collected information about household composition, income, consumption/expenditure, borrowing and entrepreneurship. For the third wave only, we also measured aspects of households' social networks. However we could only collect partial network data across the 104 neighborhoods in Hyderabad, so instead we collected Aggregated Relational Data . Because we collected this information only in the 2012 Wave 3 data, the majority of our analysis uses Wave 3 only; an exception is the analysis of consumption smoothing which leverages the panel nature of the data. Specifically, an average of 55 households in every neighborhood in the Hyderabad sample were surveyed and asked a set of network questions. First, respondents were asked how many links they had within the neighborhood along three dimensions: financial, social and informational.11 This is the directly solicited part of the network information. Second, respondents were asked 9 ARD questions of the form "How many individuals from your neighborhood do you know who have trait X?" For instance, traits include "How many other households do you know where there are 5 or more children?" and "How many other households do you know where any member is a permanent government employee." Supplemental Appendix E.1 details both types of survey questions. Third, we asked each sampled household whether they possessed each of the ARD traits. We use the method of Breza et al. to leverage ARD data to estimate key network characteristics. We give a more detailed description of the algorithm in Supplemental Appendix E.2. ARD counts the number of links an agent has to members of different subgroups in the population. The basic idea is that by combining this information with a model of network formation, one can estimate which possible networks would have generated this sample. Specifically, we assume a "latent distance" model, where the probability of a connection depends on individual heterogeneity and the distance between pairs of nodes in a latent social space . Basically, by triangulating the information about how many nodes of each type a given respondent knows, we can learn a lot about where the individual is likely to be located in the latent space. This allows us to estimate a distribution over possible network configurations that could have generated this sample information. We can then generate graphs from this distribution and compute network statistics for each generated graph. For many applications, that information about the potential networks is enough to draw relevant conclusions. 12 Here we are mainly interested in the frequency of different types of relationships, which is easily recovered from ARD. Note that the way we elicited the ARD means that we only have information about one single type of link encompassing all dimensions of interaction, both financial and non-financial. 13 2.3. Sample Statistics and Covariate Balance. Table 1, Panel A shows Wave 1 network characteristics by treatment status in Karnataka, while Panel B shows Wave 1 household demographics. The networks are sparse: the average density is 11.9%. The average clustering coefficient is 0.33. Finally, these networks have short distances: the average closeness is 0.379. 14 In general, the network structure and demographic variables look quite similar between the microfinance villages and non-microfinance villages at baseline. However, the MF villages are larger, on average, than the non-MF villages. 15 We further examine baseline balance on an expanded range of demographic and village-level covariates in Online Appendix Table C.1, Panel A. Next we turn to Hyderabad. Recall that since we have an endline cross-section, we only measure the network characteristics after the intervention to test for balance. In Online Appendix Table C.2, we show the means of select network characteristics in control neighborhoods. In this urban sample, the networks are even more sparse than Karnataka; the average degree is 6.0, for an average neighborhood size of approximately 200 households. Average clustering and closeness are also smaller. In Table 1 Panel C, we present sample statistics and tests of covariate balance using a set of predetermined neighborhood and household characteristics. Given that the introduction of microfinance was randomized in the Hyderabad sample, the covariates are 12 For example, Breza et al. shows that ARD data can replicate the results of Breza and Chandrasekhar as well as if the entire network was observed. We also validate ARD in the Hyderabad dataset. Specifically, in the surveys, we directly measured support -the likelihood that for any link, there exists a third person who has a relationship with both nodes. We validate ARD by comparing the estimated measure of support using the ARD algorithm with the directly elicited survey measure. In this way, we can show that the ARD estimate leads to the identical conclusions. 13 The ARD algorithm requires information on the total population of each neighborhood. Unfortunately, we were unable to collect this information for 15 of the 104 neighborhoods. Therefore, in specifications that use population as an input , we drop these neighborhoods from the analysis. 14 In order to deal with the fact that we sampled data in Wave 1, we compute average density among the sampled households in Wave 1, comparing the share of realized links relative to potential links when we fully observe the potential link. We compute the clustering coefficient among the subgraph induced by restricting to sampled households in Wave 1, since that is centered around the true parameter. It is also worth noting that the correlation among the different link types is 0.638. 15 In Online Appendix M, we show that our main results are robust to allowing for differential trends by functions of village size. balanced in treatment and control. Again, Online Appendix Table C.1 includes an expanded set of pre-determined covariates. --- Classifying Nodes as H and L. In order to study heterogeneity in effects by propensity to participate in microfinance, we need to identify which households would have had taken out microfinance loans in the non-microfinance villages or neighborhoods, had BSS or Spandana entered those villages. To do this, we use a random forest model to classify an individual's propensity to take up microfinance as a function of baseline characteristics, in the presence of microfinance. We can then use this classification exercise to predict which individuals in the entire sample have a high propensity to borrow. We begin with the Karnataka setting. One obvious determinant of microfinance take-up is from the BSS rules: only households with a female in the age range 18-57 were eligible for microfinance. Also, certain households were identified by BSS as a "leader" household and were specifically informed about the product. 16 Therefore leaders, or people close to them in the network, are more likely to have heard of the microfinance opportunity and have taken it up . We estimate the random forest model based on household demographics and network characteristics from the microfinance villages on a training sample of 7199 households and then validate the method on a testing sample of 2399 households. The features are as follows: a dummy for the household being a BSS leader, which are households with an individual that the microfinance institution would approach when entering a village; a dummy for whether the household has a female of eligible age , which was a requirement to be able to participate in microfinance; the average closeness to leaders, which is relevant, because as in Banerjee et al. , those who are closer to leaders should be more likely to hear of microfinance; the average closeness to same-caste leaders, because interactions within caste are more likely and therefore should influence the likelihood of being informed; and the share of same-caste leaders in the village. The details of the estimation algorithm, implemented choices, and quality are presented in Appendix B. Turning to the Hyderabad setting, the strategy is similar, though Spandana did not have such clear rules for selecting borrowers. Thus, we consider 19 predictors of a household's take-up of Spandana, including demographic characteristics of the household as well as demographic data for the village . We again use random forests, training a model on 2520 households and then validating the model on a testing sample of 1080 households. We then apply the classifier to both microfinance villages and nonmicrofinance villages to classify each household as H or L . A major advantage of using random forests is that they naturally allow for non-linearities and potentially complex interactions between characteristics that could drive microfinance take-up. If the likelihood of being a microcredit taker or not is very non-linear in the characteristics, then random forest provides a very sensible and flexible approach. Alternatives such as logistic regression would not be able to handle such interactions and non-linearities without typically introducing a very high dimensionality of interaction terms. A related advantage of random forest comes from its value in identification. Because random forests allow for classification via a complicated non-linear function of the network and relation to leadership positions, in the Karnataka data where we have baseline network data, we can control smoothly for network position and network position interacted with post. Therefore, unobservables correlated smoothly with network parameters are unlikely to drive the Karnataka results. Random forest classification does have a few downsides. First, because of the highly nonlinear structures that can arise, the actual mapping from characteristics to classification are less interpretable than with logistic regression models. This is not a major problem in our case, since we are more interested in prediction than interpretation. Second, if the true underlying data-generating process has log-odds that are linear in parameters, then the random forest may overfit. Therefore, for robustness, we also present our main results in Appendix K using logistic regression to classify households into H and L types for both Karnataka and Hyderabad. In Appendix Section B.5, we show that random forest outperforms logit in both samples in terms of typical classification quality metrics. Further, all of the results are replicated in the Karnataka sample, where logit classification is at least comparable to the random forest. In Hyderabad, logit classifies types much worse.17 Table 2 presents some summary statistics from the classification exercise. In Panels A and B we look at Karnataka data. There are notable differences between H and L households. Although none of these features were used in the estimation, we find that H households are much more likely to be SC/ST, have smaller houses in terms of room count, are much less likely to have a latrine in the household, and are much less likely to have an RCC roof, all of which suggests that they tend to be poorer. Finally, we see that H households have somewhat larger degrees than L households, and the composition exhibits homophily: H types have a lower number of links to L types and a higher number of links to H types. Finally H households are more eigenvector central in the network, which is not surprising given that they were selected to be close to leaders, who themselves tend to be more central. In Section 5.1 we show that indeed H types borrow considerably more than L types in microfinance villages. H types borrow Rs. 1,787 more than L types, indicating that the classification performs well. Panels C and D turn to the Hyderabad data, and look only at the non-microfinance villages. In Panel C, in contrast to Karnataka, we find no significant difference between H and L households in their demographic characteristics. Turning to network characteristics, in Panel D we see, like in Karnataka, that H types have fewer links to L types, more links to H types, and are more central. Again, in Section 5.1 we show that one year after microfinance entered the treated neighborhoods, H types had considerably more microcredit than L types in early microfinance neighborhoods . --- Changes in Networks How does exposure to microfinance change networks? We begin with a discussion of how the overall structure of social networks are affected and then the effects on different types of bilateral links as well as triads. 3.1. Effect on the total number of links. We first look at how introducing microfinance affects the overall structure of the village social networks. In the Karnataka data, where we have a panel but no randomization, we use a difference-in-differences framework: y = α + βMicrofinance v × Post t + γMicrofinance v + ηPost t + δ X v + vt , where y computes the density of the network g vt for village v in period t, the average closeness , or clustering. The density is the percentage of links a random household has to all other households in the village, so it measures how wellconnected the village is on average. 18 The distance in the network is the number of steps through the network it takes to get from one household to another. In models where favors, transactions, or information travel through the network, higher distance or lower closeness means that the movement of such phenomena through the network is slower. Finally, clustering is the share of a household's connections that are themselves connected. Economic models of network formation identify clustering as an important feature to sustain cooperation. In the Hyderabad data, where we only have endline data, we run a cross-sectional specification. X v is a vector of control variables, which varies according to the specification. Table 3, panel A presents the results for Karnataka. Columns 1-3 present the result for network density, columns 4-6 for clustering, and 7-9 for closeness. The first column in each category present a simple difference in differences specification. The second column in each specification adds to that a vector of baseline controls interacted with textP ost t as well as the controls interacted with treatment and Post t . These controls include share of upper-caste households, number of households in the village, network density, share of households in self-help groups, share Hindu, share with a latrine in the house, share that own the household, share that have electricity and share that are leaders. We add these because differences in the size of the village, caste composition, or the wealth distribution could potentially have differently-evolved networks even without introduction of microfinance. While the entry of BSS does not seem to correlate with much of anything beyond village size, we include these controls to ensure that they do not drive the results. Finally, the third column in each specification includes village fixed effects as well as controls for the baseline value of the outcome variable interacted with Post, to allow for differential time trends by baseline network feature. Because we only have 150 observations but many controls , we use the double post-LASSO procedure to select the controls. 19We find that exposure to microfinance leads to a drop in density by about 1.2-1.3pp relative to a mean of 11.4% in non-microfinance villages in Wave 1 . This is an 11% drop in density. We don't find any detectable effect of microfinance on the clustering of the village. This is true irrespective of whether controls are used. Without controls we find a significant decrease in the average closeness , corresponding to a 0.53 standard deviation effect. However, this loses significance in columns 8 and 9 with the inclusion of controls . Panel B turns to the Hyderabad data, which uses an endline cross-sectional dataset rather than a panel, but takes advantage of the random selection of neighborhoods to treatment. There, we run the following specification. y = α + βMicrofinance v + δ X v + vt , Our vector of controls X t are demographic characteristics of the household and the village, the same ones used for classification of H and L. We again use DPL to select the control variables. We find that there is a 22% decline in density . We do not find meaningfully significant results on clustering or closeness. Thus, in both settings, we find a reduction in the density of the network. --- How are links affected by microfinance? In this subsection, we explore how microfinance exposure affects the formation of links across types of households -our Hs and Ls. Bilateral links can be of three types: HH, LH, and LL. Let g ij,v,t be an indicator for whether a link is present between households i and j in village v in wave t. Letting LH ij be an indicator for pair consisting of one low type and one high type, and analogously for HH ij etc., the regressions we run take the form g ij,v,2 = α + βM F v + β LH M F v × LH ij,v + β HH M F v × HH ij,v + γ LH LH ij,v + γ HH HH ij,v + δ X ij,v + ij,v,2 , where X ij,v includes a vector of flexible controls for centrality of both nodes, demographic variables , all variables that are used in the random forest classification, and then interactions of all of these variables with the microfinance dummies . The idea behind identification is that the classification type, H or L, is a complex, non-linear function with many interaction terms of a subset of the features described above. As such, we can still smoothly control for them and allow the control to vary by whether the village is exposed to microfinance or not. This allows us to control for the potentially differential effect of microfinance exposure on households that are demographically distinct and located differently in the network under the maintained assumption that these effects can be capture by linear uninteracted terms. The coefficients of interest capture whether being in a microfinance village differentially affects the evolution of a link among types classified as HH, HL, and LL, conditional on all the characteristics above and their interaction with MF. We also present regressions without any controls whatsoever to demonstrate that the results are robust to the presence or absence of these detailed controls. Altonji, Elder, and Taber show that if the results do not change when we introduce more and more controls, this provides some support for the view that unobservables are not spuriously driving the results. We run these regressions in two samples: the set of ij such that g ij,v,1 = 1 and the set where of ij such that g ij,v,1 = 0 , in which case we ask about the probability of a new link forming in Wave 2. Table 4 presents the link-level results for any type of relationship in the Karnataka data. In columns 1-2 we focus on the set of links existing in Wave 1 and in columns 3-4 we focus on the set of unlinked nodes in Wave 1. Columns 1 and 3 include no controls whatsoever. Columns 2 and 4 introduce the set of controls variables and their interaction with MF, selected by double-post LASSO. The key coefficients for testing the hypotheses are the coefficients on Microfinance, which captures the effect on the omitted category, LL, links, as well as Microfinance×LH coefficients and Microfinance×HH, which ask whether the effects are different for these types of links, compared to LL. Columns 1 shows that LL links break significantly more in MF villages relative to non-MF villages. Specifically, they are 5.8pp less likely to exist in Wave 2 , on a base of 48.2% in non-MF villages. The decrease in LH links is very similar, while the HH links are somewhat less likely to disappear . The results are robust to the inclusion of control variables. Columns 3 and 4 present similar results for link formation. LL links are 2.3pp less likely to form in microfinance villages on a base of 7.5% in non-microfinance villages . Again, the effect is comparable for LH links, while it is less pronounced for HH links. All of these results are robust to smoothly controlling for the centrality of nodes involved as well as demographic controls and their interactions with microfinance. The relative changes in network structure in the microfinance villages shed light on network formation. The fact that the LH links break might reflect the fact that the Hs are no longer interested in maintaining their links with the Ls now that they have an alternative source of credit, but the fact that LL links are equally likely to break is more surprising, especially since the Ls should have a stronger incentive to hold on to their mutual links precisely because they no longer have access to the links with the Hs. 20We turn to the Hyderabad data in Table 5. In this case, we have only cross-sectional information on networks so we cannot condition on pre-period link status. Therefore we run the regression in the sample of any possible link ij. The "microfinance" coefficient identifies the effect on LL links and captures a combination of link formation and link destruction. Column 1 includes only the randomization strata as controls, while column 2 additionally allows for any of the household or village level controls used in the random forest classification to be included. In column 1, we find a 0.6 percentage point decline in the probability that an LL link exists in microfinance neighbhorhoods relative to non-microfinance neighborhoods . We cannot reject that the estimates for LH and HH are the same, but they are imprecisely estimated. The estimates are quite similar in column 2, after adding controls. We next unpack these findings for financial links versus information links. Table 6, Panel A presents the results in the Karnataka data, where columns 1 and 2 consider the evolution of financial links, while columns 3 and 4 consider non-financial links. Columns 1 and 3 restrict to links of each type that existed in the Wave 1 data, while columns 2 and 4 restrict to pairs of individuals that were not linked in Wave 1. The patterns are strikingly similar across financial and information links, which is evidence of multiplexing. In fact, for information links, we find that the disappearance of HH links is significantly smaller than that of LL links. In the Hyderabad data, recall that the link-level information analyzed in Table 5 is constructed using ARD, which defines a link as a relationship occuring on any dimension , so we cannot run an exactly parallel specification. However, we did collect supplemental, node-level information on relationship type that allows us to explore whether microfinance affects financial and non-financial links differentially. Panel B of Table 6 presents household-level regressions where the outcome variable is the number of financial or non-financial links, and the regressors are M F and M F * H . The main effect of M F identifies the effect of microfinance exposure for L households. It is is negative and highly significant on both the number of financial links and the number of non-financial links. The interaction effect, Microfinance×H , identifies the differential effect of microfinance access for H households, those with high propensity to borrow. The interaction effects are positive and significant for all outcomes considered. The total effect for H households is in fact positive for all outcomes. As in Karnataka, non-financial links have similar patterns as financial links, consistent with multiplexing. And while H households appear to hold steady or even gain links in response to microfinance exposure, the L households clearly and unambiguously lose links. --- Group Relationships. In the link-level analysis we show that LL links -relationships between two individuals who experience minimal, if any, direct impacts from microfinanceare at least as likely to be affected as relationships involving H types. One natural place to look first to try to understand this result is local payoff externalities: does the decline in LL links stem from these housesholds' links to other H households who join microcredit? Bloch, Genicot, and Ray , Ambrus, Mobius, and Szeidl , Jackson, Rodriguez-Barraquer, and Tan all propose models where contract enforcement requires groups of nodes rather than simple pairs. In Jackson, Rodriguez-Barraquer, and Tan , for example, two households seeking to exchange favors may not have enough bilateral interaction to be able to sustain cooperation in isolation. However, if they both have relationships with some other households in common, then the relationships can all "support" each other and provide incentives to cooperate: if someone fails to cooperate with one of their friends, then beyond losing that relationship, they can also lose relationships with all of the other friends that they had in common. Our network data exhibits such groupings, with the rates of a group of nodes being collectively linked far exceeding the rate to be expected if decisions were made independently . These interdepencies in link formation may explain the impact of microfinance on LL links. If there are payoff externalities, L types might value an LL link more when there is a third node involved. The introduction of microcredit could destabilize these structures. In groups that are composed of both L and H types, it could be the case that microfinance directly causes LH links to break, which in turn spills over to adjacent LL links in the same group. In this world, groups only composed of L links should experience minimal impacts. The direct testable implication is that, if we focus on triangles that existed in Wave 1, we should see a larger decline in triangles involving at least one H than in LLL triangles. We use the following regression specification to test this hypothesis: y ijk,v,2 = α + βM F v + β LHH M F v × LHH ijk,v + β LLH M F v × LLH ijk,v + β HHH M F v × HHH ijk,v + γ LHH LHH ijk,v + γ LLH LLH ijk,v + γ HHH HHH ijk,v + δ X ijk,v + ijk,v,2 , where y ijk,v,2 is either a dummy for whether the triangle ijk exists in Wave 2 in some specifications or whether any link in the former triangle exists in Wave 2 in other specifications. The vector X ijk,v includes flexible controls for centralities of households, demographic characteristics previously described for all households, all classification variables used in the random forest model and the interactions of all of these variables with microfinance. As before, we present regressions with and without control variables. Table 7 presents the results in the Karnataka data. In column 1, we find that all triad types break faster in microfinance villages relative to non-microfinance villages. However, LLL triads that existed at baseline are the most likely to break in microfinance villages. Specifically, they are 7.8pp more likely to dissolve in microfinance relative to nonmicrofinance villages . LHH triangles and HHH triangles are both statistically less likely to dissolve than LLL triangles . The results are similar, if less precise, with control variables. Similarly, in column 3, we see that, out of formerly-linked triangles, we are more likely to see that none of the links survive for LLL triangles in M F villages , and that this is significantly less likely to occur for LLH, LHH, and HHH triangles. Table 8 presents the Hyderabad results and measures whether microfinance affects the event that a given set of three households are all linked . Because the likelihood of any potential triangle being fully linked is low , we scale all regressors by 1,000, for readability. 21Although the results are noisier than in Karnataka, we find once again that LLL triangles are negatively affected by microfinance: in column 1, we are 60% less likely to see any LLL triangle in MF neighborhood . The effect is the same for LHH and smaller for LLH . The only difference is that HHH are the triangles who appear to be most likely to be missing in MF villages. In summary, while there is evidence for interdependencies in the persistence of network relationships in our data, we find that microfinance affects LLL triangles particularly strongly. This suggests that models of local externalities are unlikely to be able to explain our results. The next section proposes an alternative model that can better rationalize them. --- A Model In this section we present a new model of network formation that is consistent with what we see in the data. The model provides new perspectives, both on how opportunities to interact arise and on how multiplexing works. The externalities in the model do not take direct forms like value of friends-of-friends, or support, or other link interactions that are often used to incorporate externalities; they instead arise more globally in the search process by which people make and maintain friendships . We present the model for links and then describe how it can be extended to cover triads. As the model is useful beyond the current setting of microfinance, we describe it in a general form and then specialize to the two-type microfinance case. --- Types and Utilities. There are n individuals, indexed by i, j... ∈ {1, . . . , n}. Agent i has a type θ i from a type set Θ. Let v θθ denote the base benefit that an agent of type θ gets from a relationship with an agent of type θ . For example, in our context, this can come from borrowing and lending activities, as we discuss in more detail below. The realized utility from a relationship also involves an idiosyncratic noise term ε ij that i gets from being friends with j. This could be personality compatibility, or some other benefits. Thus, an agent i gets a value v θ i θ j + ε ij from a connection with j, where ε ij is distributed according to an atomless distribution F . A useful expression is E + [v] = E [v + ε ij |ε ij > -v ] = v + ´∞ -v ε ij dF ´∞ -v dF , which denotes the expectation of v + ε ij conditional the value of v + ε ij being positive. This is the expected utility that an agent gets from a relationship with base value v, conditional upon being willing to form the friendship. An agent of type θ then has an expected utility from d θθ friends of type θ of θ ∈Θ d θθ E + [v θθ ]. 4.2. Efforts and Link Formation. Each agent chooses an effort e i ∈ [0, 1], which represents the amount of time they spend socializing to form and maintain links. In the case of the villagers, this could be time spent in the town square or tea shop, where they meet with other villagers. 22 As will become evident, our model is meant to capture both link formation and link maintenance. Two agents i and j who have chosen efforts e i and e j have probability proportional to e i e j of meeting. The model therefore rules out "directed search" since the probability of meeting is independent of the agent's type, conditional on their effort. Time goes in periods t ∈ {0, 1, 2, . . .}. Let g t ∈ {0, 1} n×n be the adjacency matrix representing network at time t. If g t-1 ij = 1, then those agents were connected in the last period and they keep their friendship if they meet with each other during time t -keeping the relationship requires seeing each other. Therefore agents i and j keep their friendship with probability e i e j and lose it with probability 1 -e i e j . If g t-1 ij = 0, then agents i, j were not connected in the last period and form a friendship with probability e i e j 1 -F (- v θ i θ j ) 1 -F . This is the probability that they meet and they both find the friendship of positive value -a friendship requires mutual consent in our model. Thus, the efforts of agents do two things: they maintain old relationships by continuing an interaction but also allow them to meet new people. --- Steady-State Equilibrium. A steady-state equilibrium is a list of efforts θ∈Θ , and a corresponding set of expected degree levels θθ ∈Θ 2 such that e θ maximizes each agent's expected utility, and the expected degree levels are in steady state as generated by the efforts. 23We prove in the Appendix A that in all equilibria all agents of the same type choose the same action, and that the equilibrium is unique, provided that costs of effort are large enough. The requirement that degrees are in steady state and generated by the efforts can be formally represented as follows. Let n θθ denote the number of agents of type θ with whom an agent of type θ could potentially form friendships. If θ = θ then this will generally be the number of agents of type θ ,24 while if it is of type θ then it will less by one to account for the agent herself. Out of those agents only an expected fraction of ) ) will ever be friends with an agent of type θ, given the mutual consent requirement. Thus, let m θθ = n θθ ) ) . This is the effective size of the pool of agents of type θ with which an agent of type θ will be friends over time. Degree at the end or beginning of a period is then the maintained relationships plus the new ones formed: d θθ = e θ e θ d θθ + e θ e θ , which simplifies to d θθ = m θθ e θ e θ = n θθ ) ) e θ e θ . Thus, in steady state, the degree is then proportional to the number of available agents of the other type, weighted by the probability that there is a mutual compatibility, and by the socializing efforts. The expected utility of an agent involves the benefits from relationships, the costs of socialization, -1 2 c θ e 2 θ , as well as a benefit just from from socializing, u θ e θ . An agent may get some value from going to the town square or getting tea, etc., independently of who else is there. Overall this leads to a utility of V θ = u θ e θ - 1 2 c θ e 2 θ base socializing benefit and cost of effort + θ ∈Θ E + [v θθ ]d θθ e θ e θ expected maintenance of existing friendships by effort + θ ∈Θ E + [v θθ ] e θ e θ expected new friendships from effort Using the expressions for m θθ and d θθ , we can write this as V θ = u θ e θ - 1 2 c θ e 2 θ + θ ∈Θ E + [v θθ ]n θθ ) ) e θ e θ . If we take u θ > 0, c θ > 0 for all θ and E + [v θθ ] ≥ 0 for all θ, θ , then an equilibrium requires that:25 e θ = min    1, 1 c θ   u θ + θ ∈Θ E + [v θθ ]n θθ ) ) e θ      . 4.4. Equilibrium Existence and Some Comparative Statics. This is a game of strategic complements, and for such games equilibria exist and form a complete lattice. 26 If u θ = 0 for all θ, then there exists a corner equilibrium in which all agents exert 0 effort. To examine the more interesting case, we presume that u θ > 0 for all agents, so that agents gain some utility from socializing regardless of the connections they form from it. In this case, for high enough costs of socialization there exists a unique equilibrium which has the property that there are spillovers from a change in the preferences of any type on the effort choices of all other types. The following result is proven in Appendix A. Proposition 1. Let u θ > 0, c θ > 0 for all θ. For sufficiently large c θ > 0's, there is a unique equilibrium and it is stable 27 and interior , and agents of the same type take the same efforts. In addition, if E + [v θθ ] > 0, n θθ > 0 for each θ, θ , 28 and v θθ is reduced for some θθ , then e θ decreases for all θ , and d θ θ decreases for all θ θ . The characterization of equilibrium is as follows. Let u be the |Θ|-dimensional vector with entries 1 c θ u θ and E be the |Θ| × |Θ| matrix with θ, θ entries 1 c θ E + [v θθ ]n θθ ) ) . Then the unique equilibrium is given by e = -1 u, which we show is well-defined for large enough costs in the Appendix A. A major implication of the proposition is that a reduction in the returns from any type of relationship decreases all efforts and degrees. The decrease in value v θθ for some θθ directly affects their efforts, decreasing those. Then, given the strict strategic complementarities, there is then a decrease in other efforts; and the feedback can lead to a substantial drop in all efforts. Note that the relative drops in efforts and degrees predicted in Proposition 1 are not necessarily ordered across groups: degree can fall most among groups of nodes that experience no direct decline in link valuation . The intuition is that if marginal benefits to Ls from connecting to Hs are particularly high, then when Hs drop effort, payoffs for Ls from effort can drop even more than for Hs, leading to an even larger effect on Ls. See Online Appendix N for a simulation demonstrating this phenomenon. 4.5. Externalities in Network Formation. Even though our model does not include direct externalities in payoffs between links, the network-formation process still exhibits significant external effects since agents' decisions to form links affect others' potential payoffs and their network formation decisions . This makes a point beyond the current setting: network formation can be inefficient not simply because of direct externalities in relationships, which is how it is usually modeled, 29 but also because meeting people requires effort, and this naturally generates strategic complementarities and substantial externalities. 27 Slight changes in efforts lead to best reply dynamics that converge back to the equilibrium. 28 All that is needed for this result is that this holds for a cycle of θ and θ that include all types. Note also that E + [v θθ ] > 0 does not require that all people form links, just that there is a non-zero probability that any two types could find a high enough noise term to form a friendship. 29 This class of models can incorporate, inter alia risk sharing, information sharing, and network support. For references see Jackson ). 4.6. Specializing to Microfinance. We next present a specialized case of the model to analyze how microfinance changes incentives for socialization. We first present the steady-state conditions for the case of two types, H and L. We then discuss how the introduction of microfinance maps to the model parameters, specifically the v θ,θ s. 4.6.1. Two Types. We now specialize the model to the case of two types: Θ = {H, L}. Let λ be the share of H types in the population. In this case, a steady-state is a solution to the equations: c H e H = u H + E + [v HH ] ) 2 e H + E + [v HL ] n ) ) e L , c L e L = u L + E + [v LL ] n -1) ) 2 e L + E + [v LH ]λn ) ) e H , d HL = n) e H e L ) ) , d LH = d HL λ 1 -λ , d HH = 2 ) 2 , d LL = n -1) 2 ) 2 . The equilibrium vector of efforts and network structure are determined by this system. 4.6.2. Application to Microfinance: An Example. How does the entry of microfinance affect these parameters? Here, we present a rationalization for the payoffs based on informal borrowing and lending. In particular, let the values v θθ be interpreted as "financial" payoffs from borrowing and lending. This tells us how v HH , v HL , v LH , v LL change in response to Hs getting microcredit. Lending produces a net return of r, which represents the effective expected interest rate from informal loans less the opportunity cost of funds. Borrowing leads to a return net of repayment of b, which represents the difference between the interest rate charged by a network "friend" and the opportunity cost of foregoing that loan . Generally, we expect b > 0 and b > r, 30 as otherwise such relationships make little sense. Whether r is positive or negative is not obvious since there are clearly social expectations to help out friends in need , and may depend on context. A household can be in one of three states of the world: they have money to lend, they need to borrow, or neither. An H household has a probability α H of having money to lend and a probability β H ≤ 1 -α H of needing to borrow, and with the remaining probability 1 -α H -β H neither occurs. There are similar probabilities α L and β L for the L types. The base payoff to an agent of type θ ∈ {H, L} of being matched to agent of type θ ∈ {H, L} is then v θθ = α θ β θ r + β θ α θ b. As in the general model, we assume that expected utility is additive across all relationships and that pairwise payoffs v θθ are independent of other friendships. 31The introduction of microfinance changes these parameters. There are several likely channels by which the introduction of microfinance affects the payoff parameters of H types from linking to others. Access to microcredit might impact both the demand and supply of informal loans by H types. If access to microcredit substitutes for informal loans, then we would expect β H to decrease. If alternately, the weekly required repayments are burdensome to households, they may have to cut back on lending smaller sums to others in the village and may even start borrowing small amounts to repay the loans when cash is short, leading to a decline in α H and perhaps an increase in β H . In addition, if there are complementarities between formal and informal loans because receiving a MF loan allows the household to overcome a non-convexity 32 , β H could go up. In contrast, if re-lending of formal credit to network partners is common, a type H may have a probability α H ≥ α H of being able to lend once she gets access to microfinance. Her probability of needing to borrow may also go down to β H ≤ β H , if microfinance loans are a substitutes for network credit. In any case, we maintain that the Ls' needs for borrowing and lending are unaltered by the introduction of microfinance. Let ∆β H = β H -β H and ∆α H = α H -α H be the changes in the probabilities that the H types have borrowing and lending needs after microfinance. By our previous assumption, ∆v LL = 0. Let ∆ θθ denote the resulting change in v θθ . To get a feeling for how this depends on ∆α H and ∆β H , note that for small values of ∆α H and ∆β H , we get approximations ∆ HH = ∆ LL = 0 ∆ HL = α L ∆β H b + β L ∆α H r ∆ LH = α L ∆β H r + β L ∆α H b. As we describe above, the arrival of microfinance may impact the valuations through a range of mechanisms. Different mechansims imply that ∆β H and ∆α H could each be positive or negative, making it very hard to say anything general about the signs of these expressions. For example, consider the special case in which α L = α H , β L = β H and α H ∆β H + β H ∆α H = 0. In this case ∆ HH = 0. Meanwhile, as discussed above, we expect b -r to be positive. Then ∆ HL should be positive whereas ∆ LH should be negative as long as ∆β H > 0 and ∆α H < 0. 33 Given that different valuations move in different directions, the prediction of how the different types should respond is unsigned. However one obvious special case is when both α H and β H go down. In this case, as long as both b and r are positive, it is easy to see that all of v HL , v LH and v HH must go down. Thus, Proposition 1 applies, implying that e H , e L , d HH , d HL , d LH , d LL should all fall. However, the relative declines in degree across groups are unsigned. In Online Appendix N, we use simulations to show that it is indeed possible that LL links may be most affected, given the decreased effort of Hs as well as the Hs' lower propensity to want to link with Ls given their decreased borrowing needs. If this payoff drop is large enough for Ls, given their original benefits from connections to Hs, this can lead to a larger drop in Ls' efforts, and hence in LL links. --- 4.7. Extensions of the model. The simple model can be extended in several directions. First, the model is solved in steady-state. Adding a population of unlinked agents to the population of the unmatched is straightforward, as is having agents exit. Second, our basic model also has no place for triads, which we previously saw to play a key role. This can be added directly, simply by having triples meet if they are all present in the town square. The extension is straightforward and thus omitted for more detail on such an extension). In such a model, analogous to the pairs case above, it would be direct that LL and LLL could decline more than their counterparts . Third, note that it is plausible that when one aspect of a relationship becomes less important, there is some risk that the entire relationship breaks up, since there is a fixed costs of maintaining a relationship. By adding other types of links that are maintained and formed at the same time as financial links, the model can generate similar effects on other links as well. As we saw above in Table 6, when we look at advice-based links, the effects are more or less of the same magnitude in proportional terms and in the same direction as the financial links. 4.8. Alternative Explanations. In this section we try to address two issues. First, can we account for the facts without going to a model with undirected search while maintaining our assumptions about changes in payoffs? Second, are there alternative assumptions about changes in payoffs that can help us account for the facts in combination with a simpler model of network formation? 4.8.1. Alternative models of network formation. In Appendix D, we discuss four other models of network formation, variations of which are already in the literature. We show why one needs a model that goes beyond those models to generate the patterns in our data. As such, our work contributes to the literature on network formation by introducing a model that combines features of different existing models, and showing why that combination of features is needed to match what we observe in the data. Previous models of network formation that involve explicit choice by agents 34 have three flavors: models in which people have the opportunity to connect with whomever they want, subject to reciprocation ; Dutta and Mutuswami ; Bala and Goyal ; Currarini and Morelli ; Jackson and Van den Nouweland ; Herings, Mauleon, and Vannetelbosch ; Jackson, Rodriguez-Barraquer, and Tan ; Boucher ); models in which there are exogenously random meetings and then, conditional upon meeting, people choose with whom to connect ; Jackson and Watts ; Christakis, Fowler, Imbens, and Kalyanaraman ; König, Tessone, and Zenou ; Mele ); and models in which people put in some effort to socialize, which then results in some random meetings, but then relationships are formed as a result of those efforts without further choice ; Cabrales, Calvó-Armengol, and Zenou ; Canen, Jackson, and Trebbi ). First, the empirical patterns that we observe here require a model with some externalities in the efforts to search and meet, which are not present in or . The basic point is that any model that gives agents full control over who they try to link with, which is what fails with undirected search, cannot explain why LL and LLL relationships drop in response to a decrease in Hs' willingness to link to Ls. 35 Our model relies on the idea that individuals put effort into trying to meet but cannot choose who they are meeting. The reason Hs lower effort less than Ls is that they are more optimistic about actually linking with those who they meet. If on the other hand, the Ls could costlessly meet with each other, or they meet people at random at no cost and can decide who to pair with, LL and LLL links should go up. Second, models in class allow for search efforts but then do not involve the choices of whom to connect to, as are present in and . This choice of whom to connect to is important in adjusting the incentives and the relative rates at which HL links form compared 34 There is also a large literature of network formation that involves no strategic choice but just a stochastic model of network formation/evolution for some description and references). Those models are not equipped to match the data here. 35 Recall that the base model does not include "friend-of-friend" effects. While models with such local spillover effects can indeed generate the fact that LL and LLL relationships drop, they cannot explain why LL and LLL relationships drop more than LH and LLH, as we discuss in Appendix D.3. to HH or LL links, which is important in our analysis. 36 Thus, the model that we introduce is a hybrid of these three classes: effort is needed to meet others and affects the relative rates at which people are randomly met, but then choice is involved conditional upon meeting. Thid, in addition, our model has two other features that help us to match the data. One is that effort is not only needed to meet new people, but also to maintain existing relationships -as the patterns we observe in the data exhibit similarities both in terms of which relationships are retained and which new ones are formed. The second is that socializing affects the opportunities to form multiple types of relationships at the same time -and so relationships are naturally "multiplexed." The combination of all four of these features -efforts to socialize with rates of meetings dependent on relative efforts, mutual choice required to form relationships conditional upon meeting, effort needed to maintain relationships, and multiple types of relationships formed at the same time -allows us to capture all of the nuances and rich patterns that we observe in the data. In Appendix D, we discuss why dropping any one of these features would fail to capture some aspects of the data. 4.8.2. Alternative models of match value. We have so far assumed that match value depends only on types and does not depend on the pattern of matching. It is possible, for example, that matches are substitutes, so that when many LH links break, the value of LL links may go up. This would predict an increase in LL links, which goes in the wrong direction. It is also possible, though perhaps less likely, that links are complements: perhaps when an L can no longer borrow from the Hs, she gives up the entire project and therefore also stops borrowing from other Ls. However in this case the LL links break because some LH links have disappeared and therefore the effect on LL links will be smaller than the effect on LH links in proportional terms. A similar possibility is that an L might want to link with another L because that second L is in turn linked to an H, and this is valuable for another reason But, as above, in this case the LL links are breaking because LH links have disappeared and so again, the effect on LL links would be smaller than the effect on LH links in proportional terms. See Appendix D.3.2 for more details. Another possibility is that the reason LL links drop is that Ls recognize that even if they don't participate in microfinance, it is available to them. This is probably true for some of them, but because we use microfinance eligibility to determine who is an L, it is less true for them than for the H . An H is therefore more likely to break their link with an L on these grounds than another L. Yet another alternative is based on the idea that the very fact that Hs tend to socialize with Hs in microfinance meetings would provide a force unique to participants, hence Hs, to form new links. This might crowd out their other links, but that would predict that LH links should decline by more than LL links . We do not find this. We further examine this alternative in Online Appendix H. We show that our main results hold even if we condition on all pairs where neither member joined microfinance . Even under this restriction, the H classification has content -Hs are more suitable for microfinance by construction, and therefore even non-borrowers have higher option value from future access to microfinance.37 However, we acknowledge that these results are only suggestive given that actual microfinance take-up is endogenous. Another possibility is a slight variant of our undirected search model where the H types simply do not have time to meet with the Ls anymore. Notice our general form of the model allows for this. A final possibility is that the entry of microfinance leads to rapid economic growth in the village, so that both H and L type don't need to maintain informal relationships any more. This is not only inconsistent with the extensive literature on microfinance, which finds little impact of microfinance entry on average village or neighborhood level outcomes such as consumption, investment or business profit for a meta-analysis), but it is also inconsistent with the household finances and borrowing that we see going on in the villages. 38 Moreover, per se, this explanation would also not account for larger effects for the L households. --- Informal Credit and Insurance 5.1. Impact on Borrowing Patterns. Next we examine how both microfinance and informal borrowing respond to the arrival of microfinance. In both the Karnataka and Hyderabad data we have rich borrowing information, and we can measure the impacts of microfinance on several different types of household borrowing . If the loss in network links corresponds to a drop in informal financial transactions, then informal borrowing should respond in a manner similar to our network results, above. We have data on the amount borrowed by source for the entirety of our sample. We begin by regressing the amount borrowed on dummies for microfinance village, post, and household type in the Karnataka sample: y ivt = α + β 1 MF v × Post t + γ 1 MF v × H iv × Post t + γ 2 H iv × Post t + γ 3 MF v × H iv + δ 1 MF v + δ 2 H iv + δ 3 Post t + δ X ij,v + ivt , where again y ivt is the amount borrowed from the stated source . Table 9, Panel A presents the results for the Karnataka data. In column 1, we find that L households do borrow from MFI , the coefficient is 477 rupees . However H borrow much more than L's do . Column 2 finds that that L households lose more from their informal network than they gain from microfinance: they lose Rs. 1045 in loans from their entire network after their village is exposed to microfinance. The H households lose additionally more, but this corresponds to their additional borrowing from MFIs. Panel B of Table 9 turns to the Hyderabad data. Here we present impacts on borrowing measured in the first post-microfinance survey wave, 15-18 months after microfinance was introduced in treatment neighborhoods.39 y ivt = α + β 1 MF v + γ 1 MF v × H iv + δ 2 H iv + δ X ij,v + ivt , Starting with column 1, we find no impact of MF on borrowing for L type in this case but a large and significantly greater impact for H types . We again observe a decline in informal borrowing for L types. All informal borrowing declines by Rs.4,341 , relative to a control mean of Rs.36,347. Here, this decline is almost entirely offset for the H types, though the difference between the two is not statistically significant . Taken together, the evidence suggests that exposure to microfinance has an adverse effect on the network borrowing of the Ls that is large enough to dominate their small potential gains from microfinance. This is especially striking because, all else being the same, we would have expected their borrowing from friends to go down less than that of the Hs or even to go up to the extent there is re-lending . 5.2. Impact on Risk Sharing. One important role of village networks is risk sharing, both through gifts and through "soft" loans whose terms are state-contingent ; Udry ). Moreover, new policies can spill-over onto others through risk sharing relationships. 40 In light of our finding that access to formal credit results in the loss of network links and a reduction in informal borrowing, it is natural to investigate whether risk sharing is also reduced. If a household's ability to buffer income fluctuations through informal risk sharing is worsened when their village has access to microfinance, the loss of network links could have a direct negative impact on welfare. Microfinance practitioners often argue that even if borrowing households do not become richer because of the loans, they should at least be better able to smooth risk through continued access to credit. However, non-borrowing L households may see a worseining of risk sharing and consumption smoothing as they have fewer links without any direct benefits from microfinance. Fortunately, the Hyderabad data contains panel information on both income and consumption 41 , which allows us to run standard omnibus tests of risk sharing. The loss of network degree is greater for the L types than the H types. In contrast, any direct benefits from microfinance borrowing are, by construction, lower for the L types relative to the H types. Thus, we expect that risk sharing should worsen for L households in treatment, compared to L households in control. The predictions are less clear for the H types, who may be able to smooth income risk using microfinance. To test this prediction, we estimate a version of the standard regression from Townsend , which allows the pass-through of income to consumption to differ by treatment status, differentially for H and L types. The subscript i indexes households, v indexes villages, and t indexes time. Microfinance villages are denoted with M F . The term α i is a household-fixed effect which, as well as controlling for the household's time-invariant Pareto weight in a risk-sharing regression, absorbs the main effect of treatment status and of type . The term γ vt is a area-time fixed effect which captures the aggregate shock to a particular neighborhood in a given survey wave. We estimate the following "long differences" specification, using the first and third waves of the data. 42 40 Angelucci and De Giorgi , for example, analyze the Progresa cash transfer program in Mexico and find that even non-eligible households consume more. Moreover, Angelucci et al. trace these impacts through the kinship network. Albarran and Attanasio also analyze the interplay between policies and risk sharing, highlighting the potential for risk sharing to go down due to improved outside options. 41 Recall, the Hyderabad data only contain network information collected in 2012, but income and consumption were collected in 2007-8, 2010 and 2012. 42 As noted by Hayashi et al. , long differences may perform better than one-period differences if income changes are dominated by transitory measurement error or transitory wage changes, or if income is known one period in advance. Moreover, in our setting, the second wave of data was collected at a point in time when both treatment and control areas had access to microfinance, which may limit our ability to detect treatment effects on risk-sharing. Results using all three waves of data are qualitatively similar but less precise, consistent with the measurement error concern noted by Hayashi et al. . c ivt = α i + γ vt + β 1 y ivt + β 2 y ivt × M F v + β 3 y ivt × H i + β 4 y ivt × M F v × H i + δ X ij,v + ivt The coefficient β 1 measures the extent of income pass-though for L households in control areas. The prediction that risk sharing should worsen for L households in treatment, compared to L households in control, is tested by the coefficient β 2 . The coefficient β 3 captures the extent of income pass-though for H households in control areas. Finally β 4 measures any differential treatment effect on risk sharing for H households. 43Table 10 presents the results. In column 1, we consider total per capita household expenditure. In column 2, we consider non-food per capita consumption, which is typically more discretionary and therefore more responsive to shocks. We find that L households in control areas experience an INR 0.059 drop in non-food consumption for a INR 1 drop in income, a 5.9% pass-through rate . However, for L households in treated areas, the pass-though increases by 0.080 . Thus, the loss of network links for L households is economically consequential in terms of worsened ability to buffer income fluctuations. The estimates are qualitatively similar for total consumption, but slightly less precise . The remaining coefficients in Table 10 consider how these patterns differ for H types. We find that microfinance causes the pass-through of income into non-food consumption for H types to decrease by 0.107 rupees, relative to the effect for L types . For these types, microfinance causes no detectable change to income pass-through . In summary, these results demonstrate that, while H households' ability to buffer income risk is unaffected by microfinance exposure, this is not true for L households. For them, the loss of network links arising from microfinance exposure has negative consequences: their ability to smooth income fluctuations is worsened markedly. Given the lack of microfinance's effect on income, these results show that the reduction in links for L types is, in all likelihood, welfare reducing. --- Conclusion By studying the introduction of microcredit to just a subset of communities in two different settings, we established that not only did the social networks change in response, but those who were least likely to take up microcredit experience substantial losses in links, even in groups where no one was involved in microcredit. This is accompanied by a loss in the ability to borrow from informal networks for those households and a reduction in their ability to smooth risk . The results were first obtained in one setting and then confirmed in a second, independent one. To explain the data, we developed a model in which agents put in effort in order to socialize, whom they meet has an undirected component, and agents engage in mutual consent to build links. Such a model features a global externality, beyond the typical externalities directly embedded in payoffs. When access to microfinance reduces a borrower's desire to maintain and form links with others, even those unlikely to join may reduce their own effort to maintain and build links. This is for two reasons: first, these low types who are linked to potential borrowers consequently have lower returns to such links ; second, because of the reduction in overall linking effort, even relationships where the direct payoffs are unaffected by microfinance can be affected. In equilibrium, those who are unlikely to be involved with microcredit may end up with the greatest losses in links. The fact that our model provides patterns consistent with the data, of course, does not imply that it is the right or only mechanism behind the empirical observations. It will take further research to develop a full understanding of the forces underlying our empirical observations. Nonetheless, the facts -in particular the evidence of negative spillovers on the non-beneficiaries -have wide-ranging and important implications. The previous literature has shown that there may be important benefits from microfinance on participant households beyond the loans themselves, especially in terms of strengthened network connections. But if this comes at a significant cost of weakened connections in the rest of the community, this could worsen the aggregate ability of a community to buffer risk. Regardless of the explanation for the changes, the more general lesson these findings illustrate is that social networks can involve spillovers, externalities, and complex relationships so that changing one part of the network can have quite extensive and unanticipated consequences. As a result, interventions into a community can change the social structure and interactions in ways that no one intended, with potentially large costs for some non-participants. Being mindful of these possibilities is important in designing effective policies. C). The network characteristics in Panel A are calulated for an unweighted, symmetric graph of households. A link is based on whether there is any of 12 relationship types between two nodes. --- Tables The "5% limit" column shows how big the difference between treatment and control would have needed to be to be significant at the 5% level. The "p-value" column shows a test of significance on the difference between treatment and control. In Karnataka, there are 75 villages in our sample and 43 received microfinance. In Hyderabad, 102 villages were subject to randomized assignment of microfinance. In Panel C we exclude 15 villages where the number of households are topcoded, as these would bias the estimates of all these statistics. Panel A: Columns 1-2 restrict to financial links, while columns 3-4 restrict to non-financial links. Columns 1 and 3 consider links that existed in Wave 1, while columns 2 and 4 consider pairs of nodes that were not linked in Wave 1. Panel B: All columns include a full set of controls. Centrality controls are a vector of flexible controls for centrality of both nodes. Household characteristics are caste and a number of wealth proxies including number of rooms, number of beds, electrification, latrine presence, and roofing material. Household predictor variables consist of all variables that are used in the random forest classification. In every case we include interactions of all of these network, demographic, and classification variables with microfinance. --- Notes: These tables present the effect of microfinance access on the loan amounts borrowed from various sources. Panel A pertains to Karnataka and tracks loan amounts from microfinance institutions, friends, family, banks and moneylenders. All of its columns control for surveyed in wave 1 fixed effects. The average rate of inflation over the period between waves in Karnataka was 8% meaning a total of 65%. Panel B pertains to Hyderabad . Outcomes are measured in the first survey wave . Here all specifications include demographic household and village controls subject to double-post LASSO. Standard errors are reported in parentheses. p-values are reported in brackets. MFI: Microfinance Institution SHG: Self-Help Group Appendix A. Proof of Proposition 1 We show there is a unique equilibrium and characterize it, here letting each agent's utility be fully dependent upon their label i. From our discussion above, it follows directly that a best response must satisfy 44 Given the bound that e j ≤ 1, and the fact that u i > 0, it follows that for sufficiently large c i , and is strictly between 0 and 1. Thus, taking c i to be sufficiently large for each i, we let u be the n-dimensional vector with entries 1 c i u i and E be the n × n matrix with ij entries Then the characterization of equilibria can be written as e = u + Ee, which has a solution of e = -1 u, given that E has nonnegative values that are less than 1 and so is invertible. Note that two agents of the same type take the same effort by the symmetry of the expected utility in type and uniqueness of equilibrium overall. Rewriting u to be the |Θ|-dimensional vector with entries 1 c θ u θ and E to be the |Θ| × |Θ| matrix with θ, θ entries the unique equilibrium is given by e = -1 u. The result on the comparative statics follows from Proposition 16 in Van Zandt and Vives , noting the strict monotonicity of the best responses in the payoffs and actions of others and the interiority of the equilibrium.

Formal financial institutions can have far-reaching and long-lasting impacts on informal lending and information networks. We first study 75 villages in Karnataka, 43 of which were exposed to microfinance after we first collected detailed network data. Networks shrink more in exposed villages. Links between households that were unlikely to ever borrow from microfinance are at least as likely to disappear as links involving likely borrowers. We replicate these surprising findings in the context of a randomized controlled trial in Hyderabad, where a microfinance institution randomly selected neighborhoods to enter first. Four years after all neighborhoods were treated, households in early-entry neighborhoods had credit access longer and had larger loans. We again find fewer social relationships between households in early-entry neighborhoods, even among those ex-ante unlikely to borrow. Because the results suggest global spillovers, which are inconsistent with standard models of network formation, we develop a new dynamic model of network formation that emphasizes chance meetings, where efforts to socialize generate a global network-level externality. Finally, we analyze informal borrowing and the sensitivity of consumption to income fluctuations. Households unlikely to take up microcredit suffer the greatest loss of informal borrowing and risk sharing, underscoring the global nature of the externality.

Life Events and SA Stressful events at any point in the life course may have important consequences for psychosocial and physical functioning in later life . Life events such as the death of significant others may negatively affect a broad range of domains of functioning, including emotional , cognitive , physical , and social functioning , and disease . The reason that life events are linked to such a broad range of outcomes is that they not only elicit stressful emotional and physiological responses in individuals but also disrupt daily routines . Moreover, a negative life event is often the culmination of a more or less lengthy process of stress accumulation, which may explain their considerable effects on health and functioning . As such, it is has been demonstrated that not only "recent" but also events in childhood or adolescence can bear life-long consequences for health in old age . The large majority of previous studies have demonstrated effects of life events only on single health outcomes within different study populations. Although this is valuable for assessing particular emotional or physical responses to stressors, we cannot infer from this literature to what extent life events affect the overall aging process. SA is fundamentally a multidimensional concept, which aims to assess the quality of overall human aging and integrates three key domains of functioning in old age, that is, physical, mental, and social functioning . Thus, one aim of this study is to estimate the effects of life events on overall functioning, as reflected by a multidimensional and longitudinal measure of SA . We are aware of two studies that investigated effects of life events on SA. Hsu found that recent events such as widowhood, offspring loss, and divorce were negatively related to various single indicators of SA. However, this study did not include earlier life events and did not estimate effects of life events on overall individual functioning. Li and colleagues found that a higher number of experienced life events during the life course were negatively associated with a composite measure of SA in a bivariate model, but not after adjusting for gender and age. This was possibly due to age and/or gender being strongly associated with both the number of life events and SA. The effects of particular events on SA remained unclear. Our study extends these two studies by including multiple life events in childhood and adulthood. Moreover, we advance understanding of inequalities in SA by situating the occurrence of life events within individual socioeconomic conditions early and later in life. --- Life Events Within the Dynamics of Socioeconomic Conditions Exposure to chronic stressors and stressful life events is not merely due to chance, but is patterned by socioeconomic conditions. Persons with a low SEP tend to be exposed more often to sources of chronic stress such as economic adversity, adverse working conditions, and deprived living environments . Within this context of elevated chronic stress, stressful life events such as family disruption or unemployment are also more likely to arise . Moreover, persons with low SEP often possess less coping resources and have less access to social support to offset or avoid accumulation of stressors . A higher exposure to stressful events may therefore be one crucial mechanism linking SEP to SA . This structural perspective on social stress implies that studies should clarify the interrelated roles of SEP and life events in childhood and adulthood, and how these affect the aging process. In the current study, we investigate several pathways linking SEP and life events in childhood and adulthood to SA. Our approach may clarify at least three issues. First, many earlier studies have neglected the fact that not all types of life events are similarly affected by SEP . Although studies show that lower SEP groups are exposed to a higher number of life events on average , the exposure to particular events such as widowhood, divorce, and assault not necessarily differ between socioeconomic groups , and divorce may be more prevalent in higher rather than lower socioeconomic groups . In our study, we therefore investigate seven specific life events, rather than summing the number of experienced life events as a proxy for lifetime stress exposure. Second, many studies did not explicitly examine the social selection hypothesis, which states that exposure to stressors may negatively affect SEP rather than vice versa . For example, parental divorce and parental death in childhood have been shown to negatively affect educational, occupational, and financial attainment later in life . Life events in childhood may also make people more susceptible to particular life events later in life. For instance, children whose parents have divorced have been shown to divorce more often themselves . It has not been studied before whether such mechanisms indirectly affect SA. Therefore, our study examines both the possibility that SEP affects life events and that life events in childhood affect adulthood SEP or stressful events in adulthood. Third, previous studies of socioeconomic inequalities in SA suggest that the direct effects of adulthood SEP on SA are stronger than those of parental SEP . However, measures of childhood and adulthood socioeconomic conditions often differed in previous studies, limiting a clear comparison of their effects on SA. It is known that different components of SEP may influence partly different indicators of SA. This suggests that multiple indicators of SEP are required to accurately capture the overall effects of SEP on SA . In our study, we use comparable and multi-indicator measures of childhood and adulthood SEP. In summary, the present study answers two research questions: to what extent do particular life events affect SA, and how are socioeconomic inequalities in SA shaped by differential exposure to life events between groups with different SEP? Specifically, we test three hypotheses, summarized in a life-course model : Hypothesis 1: Stressful life events in childhood and adulthood negatively affect SA , whereas higher parental and adulthood SEP decrease the likelihood of experiencing such events in childhood and adulthood, respectively . Hypothesis 2: Life events in childhood negatively affect adulthood SEP and therefore indirectly and negatively affect SA. Parental problems in childhood increase the likelihood of divorce in adulthood and therefore indirectly and negatively affect SA . Hypothesis 3: Higher parental SEP and higher adulthood SEP positively affect SA . Additionally, higher parental SEP positively affects adulthood SEP and therefore indirectly and positively affects SA . --- Method --- Data and Study Sample We employed data from the nationally representative Longitudinal Aging Study Amsterdam . In 1992-1993, 3,107 respondents were included in a random sample of individuals aged 55-85 years . Respondents lived in 11 municipalities in the Netherlands that reflect the national sociogeographic variation. The oldest old and men were oversampled. In 3-year cycles, data were acquired during interviews at home, in written questionnaires, and in medical interviews. Our operational definition of SA was developed earlier and is based on data from the baseline measurement in 1992-1993 and follow-up measurements in 1995-1996 , 1998-1999 , 2001-2002 , 2005-2006 , and 2008-2009 . In-between waves, on average about 12% of the respondents died and 8% could not be contacted, were too frail to participate or refused to participate. Calculation of trajectories of functioning constituting the measurement of SA was performed only for respondents who had data for at least two waves for a specific indicator of SA . For these respondents, 16-year trajectories were calculated using maximum likelihood estimation. The final study sample included respondents for which at least eight trajectories of SA were calculated . The present analyses are based on the same study sample. --- Measurements --- Successful Aging The "Successful Aging-index" is based on nine indicators of physical, mental, and social functioning . The index ranges from 0 to 9 and essentially expresses the number of indicators for which individual respondents had a favorable 16-year trajectory. The premise of this index is that the more favorable trajectories one has, the more "successful" one was. Here, we provide a summary description of the composition and calculation of the SA-index. Details can be found in the online Supplementary Material and in previous work . The SA-index is based on the widely adopted Rowe and Kahn model of SA, but incorporates several suggestions for extending this model and its measurement . First and foremost, lay perspectives on SA led us to exclude the absence of disease as a requirement for SA and to include holistic and subjective indicators such as self-rated health and life satisfaction. Excluding chronic diseases was done because few older adults age without them, and many older adults feel that having a chronic disease does not preclude successful aging . Second, "success" was based on long-term trajectories rather than a cross-sectional measurement of functioning, allowing limited functional decline as well as recovery from decline to signify SA. Third, we expressed SA on a continuum rather than as a dichotomy, which allows SA in one domain despite less favorable functioning in other domains . The following nine indicators are included in the SA-index. Functional Limitations reflects the extent to which respondents can perform six daily activities. Selfrated Health assesses respondents' health "in general." Depressive Symptoms are measured by the Center for Epidemiologic Studies Depression Scale . Satisfaction with Life reflects how satisfied respondents are with their life "lately." Cognitive Functioning is measured by the Mini Mental State Examination . Social Loneliness is assessed with a five-item subscale of the De Jong-Gierveld Loneliness Scale . Social Activity reflects the frequency of participation in thirteen types of organizations per month. Finally, Emotional Support Given and Instrumental Support Given measure how often respondents talked to their nine most frequently contacted network members about their personal experiences or feelings , and how often they helped them with daily tasks in and around the house . More details are available in the online Supplementary Material. For each of the SA indicators, latent class growth analysis in Mplus 6.0 was conducted to identify subgroups of respondents with a distinct type of trajectory. For each indicator, trajectories with stable high levels of functioning, limited decline, or recovery from a low level of functioning were evaluated as "successful" trajectories. Trajectories were calculated separately for men and women. Detailed results are available in Supplementary Material. The SA-index was constructed by summing the individual posterior probabilities of belonging to a "successful" class for each of the nine indicators, thus ranging from 0.00 to 9.00. This score reflects the number of "successful" trajectories of functioning, adjusted for the statistical uncertainty underlying latent class membership. Sum scores for respondents with one missing indicator were divided by eight and then multiplied by nine. --- Life events We selected life events that rank highly in terms of distress and influence on people's daily lives ; are likely to occur more often in particular socioeconomic groups; and had a prevalence >5% in our sample. All life events occurred before the baseline measurement in 1992-1993. In line with the notion of childhood and adolescence as "sensitive periods" , we narrowed down our definition of childhood events to those that took place before the respondent was 18 years old. Parental Death in Childhood expressed whether one or both parents had died in childhood. This event was included because low SEP is associated with early mortality . Parental Problems in Childhood expressed whether respondents reported "divorce of parents," "severe discord between parents," or "other problems at home" during childhood. This event was included because of inconclusive evidence on whether divorce more often occurs with lower SEP or rather with higher SEP . Adulthood family-related life events included Divorce , Widowhood, and Death of a Child, expressing whether respondents had experienced this at least once during their lives. Because lower SEP is associated with higher mortality and because of social reproduction of SEP , we expected a higher prevalence of widowhood and the loss of a child with lower adulthood SEP. Occupational life events included Unemployment and Occupational Disability. These events reflected whether respondents ever received unemployment or occupational disability benefits for at least 3 months. Because unemployment benefits do not apply when employees voluntarily resign, we assume that unemployment was involuntary. We expected such events to occur more often with lower SEP groups due to less secure and physically more demanding jobs . --- Socioeconomic Position We assessed parental SEP by father's education, mother's education, and father's occupational prestige. For adulthood SEP, we included respondents' education, occupational prestige of their longest-held job, and partner's education. Education of parents, respondent, and partner were measured in years . Occupational prestige was based on job type, coded into a prestige scale . Before exporting the prepared data set to Mplus, we acquired complete data on SEP by averaging SEP values from 20 imputed data sets obtained by multiple imputation in SPSS. Comparison of results between models with original and imputed data revealed no significant differences in estimates. Proportions of data imputed were 4% for father's and own occupational prestige ; 6% for father's education and mother's education, and 31% for partner's education . We imputed partner's education because we aimed to measure SEP representative for adulthood rather than at baseline. Finally, we constructed indices of parental and adulthood SEP by calculating the mean of the three standardized SEP indicators. The resulting mean scores were standardized again, such that a change of one unit in this final SEP index equals one standard deviation with a mean of exactly zero. --- Statistical Procedure We first estimated the "total" effect of each predictor on SA in separate regression models, adjusted for baseline age only. Then, on the basis of our hypothetical model , we constructed a path model including all available variables . Starting with solely the effect of Parental SEP on SA, we gradually increased model complexity until the full path model was specified. In this process, we checked all estimated paths for values that might indicate model misspecification, for example, high standard errors and negative variances . We encountered no such problems. In the path model , single-headed arrows indicate an assumed causal direction, where the dependent variable is regressed on the independent variable. Double-headed arrows assume no causal direction between variables, and only adjust for their potentially associated residuals. The latter was done for Divorce and Widowhood and for Unemployment and Occupational Disability, because both sets of events are likely to be mutually exclusive. The path model was adjusted for baseline age. Because the SA-index was calculated separately for men and women, and SEP and the prevalence of life events differed between men and women, we tested for each path whether the effect differed between genders. If we found such a difference , we estimated the path separately for men and women. If coefficients did not differ, we constrained the path to be estimated equally, adjusted for gender. Path analyses were carried out with Mplus version 6 . Because the full model includes combinations of dichotomous and continuous variables, we used a weighted least squares with mean adjustment estimator. Standard errors and statistical significance of indirect effects were obtained using bootstrapping with 1,000 bootstrap draws. This method provides more accurate estimates and more power to detect significant indirect effects than the Baron and Kenny approach and the Sobel test . Because the direction of indirect effects is apparent from multiplying the coefficients of each element included in them, we used one-tailed significance testing for indirect effects, reflected by 90% bootstrapped confidence intervals . Effects of continuous on dichotomous variables were expressed as probit coefficients, where a positive value expresses a higher likelihood of the event with higher SEP, and a negative value expresses a lower likelihood with higher SEP. In order to provide a robust estimation of model fit, we evaluated three goodness-of-fit indicators: the root mean square error of approximation , the comparative fit index , and the Tucker Lewis index . These indicators are relatively insensitive to sample size and favor parsimonious models over complex ones . To further explore the effects of SEP and life events on SA, we conducted nine logistic regression analyses, estimating the independent effects of SEP and life events on the odds of having a successful trajectory for each separate indicator of SA. A dummy variable expressing whether the respondent ever had a paid job was added in order to retain those who never had a paid job in the analyses. Detailed results can be found in Supplementary Material. --- Results --- Descriptive Analyses The mean age was 69.0 for men and 69.4 for women . On average, men had a higher number of successful trajectories of functioning than women . The prevalence of life events varied between 5.4% for Unemployment and 38.2% for Widowhood. We observed gender differences in the prevalence of Parental Problems in Childhood, Widowhood, Unemployment, and Occupational Disability. About 41.5% of men and 38.3% of women experienced none, and 5.2% of men and 4.0% of women experienced three or four out of seven life events. On average, men who reported three or four life events had 1.5 successful trajectories less than men who reported no events. This difference was about 1.7 for women. --- Total Effects Analysis of total effects, adjusted for baseline age only in separate models, showed that all life events except for Death of a Child had negative effects on SA . Parental SEP had no significant effect on SA, and Adulthood SEP had a positive effect on SA, which was stronger for women than for men . --- Life-Course Model: Hypothesis 1 Model fit indices for the full model indicated good fit to the data . The first part of hypothesis 1 predicted negative direct effects of life events on SA. This hypothesis was supported, except for Death of a Child. The estimates of the effects of life events on SA indicate the absolute difference in SA-score between those with and without the event. For instance, respondents who reported Parental Problems in Childhood had on average .31 successful trajectories less than those who did not report this event . Further negative effects on SA were found for Parental Death in Childhood , Divorce , Widowhood , Unemployment , and Occupational Disability . The second part of hypothesis 1 expected higher parental and adulthood SEP to decrease the probability of experiencing stressful life events in childhood and adulthood, respectively, and as such to indirectly and positively affect SA. Contradicting these expectations, we found that respondents with higher Parental SEP were more likely to have experienced Parental Problems in Childhood and Parental Death in Childhood . The indirect effects of higher Parental SEP through these life events on SA were negative and statistically significant . Also contradicting hypothesis 1, respondents with higher Adulthood SEP were more likely to have ever divorced and more likely to have ever been unemployed . The resulting indirect effects of Adulthood SEP on SA were statistically significant and negative . Supporting the latter part of hypothesis 1, older adults with higher Adulthood SEP were less likely to have ever been occupationally disabled or to have ever lost a child . The indirect effect from Adulthood SEP through Occupational Disability on SA was positive. There was no significant indirect effect of Adulthood SEP through Death of a Child on SA. --- Life-Course Model: Hypothesis 2 The first part of hypothesis 2 expected a negative indirect effect of childhood events on SA, through their expected negative effects on Adulthood SEP. In support of this hypothesis, Parental Death in Childhood negatively affected Adulthood SEP , and the indirect effect of this event via Adulthood SEP on SA was statistically significant and negative. We found no support for the second part of hypothesis 2, stating a negative indirect effect of Parental Problems in Childhood on SA, through increasing the likelihood of Divorce. The effect of Parental Problems on Divorce was positive, but not statistically significant . We also tested whether three-part indirect effects involving Parental SEP, Adulthood SEP, and life events were statistically significant. This was the case for three of such pathways. The pathway from Parental SEP via Adulthood SEP via Divorce on SA was negative . Parental SEP also indirectly affected SA through Adulthood SEP and Unemployment and through Adulthood SEP and Occupational Disability . --- Life-Course Model: Hypothesis 3 The first part of hypothesis 3 stated positive direct effects of Parental SEP and Adulthood SEP on SA. In the full model, we found no significant direct effect of Parental SEP on SA and a positive direct effect of Adulthood SEP on SA . These results support hypothesis 3 only for Adulthood SEP. The effect of Adulthood SEP on SA in the full model including life events was stronger than the effect without adjusting for life events. This suggests suppressor effects of life events on the association between Adulthood SEP and SA. Additional analyses showed that the relatively small inequalities in SA by adulthood SEP in the unadjusted model were due to a higher exposure to Divorce and Unemployment in older adults with higher adulthood SEP. Finally, the latter part of hypothesis 3 stating a positive indirect effect of Parental SEP on SA through Adulthood SEP was supported . --- Sensitivity Analyses In sensitivity analyses on separate SA indicators, we found that all life events were associated with at least one indicator of SA and that each single indicator of SA was affected by at least one life event. For example, widowhood was associated with lower odds of having a successful trajectory in five out of nine indicators of SA , and depressive symptoms and instrumental support given were affected by four out of seven included life events. Inequalities by Adulthood SEP were present in six out of nine indicators of SA, and largest in cognitive functioning and emotional support given. Detailed results can be found in the online Supplementary Material. --- Discussion This study was the first to examine the effects of stressful life events and SEP in childhood and adulthood on a longitudinal and multidimensional measurement of SA, while disentangling how these social and individual factors may shape one another. Contributing to the state-of-theart literature on SA, social stress, and life events, our study yielded two principal findings. First, we observed that six out of seven included life events had a negative effect on SA. Experiencing multiple of these events may substantially affect the extent to which one ages successfully. Striking was the observed negative effect of parental problems in childhood on SA, confirming that even early-life events may influence trajectories of functioning several decades later. Second, we found evidence that both early-and later-life socioeconomic conditions partly shape SA, albeit through complex and partly unexpected pathways. We found that both lower and higher SEP were associated with higher risks of experiencing particular life events. Those with lower adulthood SEP were more often confronted with occupational disability, but those with higher parental or adulthood SEP were more likely to have experienced family disruption in childhood, divorce, and unemployment. Relatively unprecedented in the literature on SA, our analyses of indirect effects demonstrated that although higher SEP remained a robust positive predictor of SA, it may also bring along particular disadvantages. Taken together, our results demonstrate some of the limits to the extent that individuals are capable of determining their chances to age successfully. Disadvantaged socioeconomic conditions in childhood and stressful events such as parental divorce and widowhood are factors that are largely uncontrollable by an individual. This calls for more research on the relative importance of controllable versus uncontrollable factors for SA. Such studies may provide indications of which policies or interventions are most likely to succeed. Moreover, our findings indicate that some efforts to increase SA in the population should focus on how adults can build resilience toward the sometimes inevitable stressful experiences and conditions in life . Building on social stress theory, our study also contributes to Rowe and Kahn's recent call to investigate how social institutions may shape opportunities or barriers to SA. We provide striking examples of how individual stress exposure can be shaped by cohort-specific institutional arrangements and norms that are linked to SEP. First, in line with previous studies , we found a higher prevalence of divorce with higher SEP. This can be explained by the observation that decades ago, couples with more cultural and economic resources could better afford to break prevailing social norms against divorce than couples with less resources . However, due to changes in legal and normative barriers against divorce, the socioeconomic distribution of divorce has shifted to being more prevalent with lower SEP . Second, our finding that women with higher education were more often unemployed can also be linked to norms that have been changing during the previous decades. In the 1950s, higher educated women were much more likely than lower educated women to combine marriage, motherhood, and employment against the prevailing gender norms . Consequently, their longer participation in paid labor might have made them more likely to have ever been temporarily unemployed. Although particular social norms and institutional arrangements may thus have changed, our results urge researchers and policy makers to analyze how contemporary societal developments affect the patterning of SA by gender and SEP. Finally, while playing a minor role in our analyses, the negative effect of the death of a parent in childhood on adulthood SEP suggests that social selection hypotheses should be taken into account in life-course studies of SA. --- Limitations A number of limitations of the present study should be discussed. First, we could investigate only a limited selection of life events. We did not include life events such as childhood abuse, physical assault, or discrimination, which might also impact on SA and be influenced by SEP. Disregard of such events was either caused by unavailability of data or very low prevalence. Second, retrospectively reported life events may suffer from recall bias. Specifically, the observed increased probability of particular life events with higher SEP might be partly due to better recall in respondents with higher SEP. However, most events included in our study are rather severe ones, which may have minimized problems with recall. Evidence from a previous study also shows no SEP differences in recall of childhood circumstances . Nevertheless, differential recall bias by SEP cannot be ruled out and may perhaps partly account for particular findings from our study for which the existing literature provides few explanations, for example, a higher exposure to parental death in men with higher parental SEP. Third, the conceptual advantage of measuring SA longitudinally rather than cross-sectionally was attained at the cost of sample attrition. Respondents who were excluded from our sample were relatively old and had lower health and education. However, they did not differ significantly in occupational prestige . Additionally, selective attrition within the final sample was minimized through using the maximum likelihood procedure in estimating the trajectories of SA. Therefore, we do not expect severely biased conclusions. As a final limitation, we emphasize that the extent to which our data allow causal inference is limited. Our conclusions regarding "social causation" and "social selection" thus are tentative. --- Conclusion Responding to the new directions for research on SA provided by Rowe and Kahn , our study has advanced understanding of how social factors and individual experiences across the life course influence SA. We showed that individual opportunities to age successfully are partly shaped by stressful life events in childhood and adulthood and that such events may be partly triggered by socioeconomic conditions. Furthermore, we demonstrated that each socioeconomic context, the advantaged and the disadvantaged, may bring along a higher risk of particular stressors that influence SA. Our results also suggest that the social patterning of particular stressful life experiences may be driven by cohort-specific cultural and institutional arrangements that should be acknowledged in research, policy, and interventions focusing on inequalities in SA. --- Supplementary Material Please visit the article online at http://psychsocgerontology. oxfordjournals.org/ to view supplementary material. --- Conflict of Interest None declared.

Objectives: Building on social stress theory, this study has 2 aims. First, we aim to estimate the effects of stressful life events in childhood and adulthood on Successful Aging (SA). Second, we examine how unequal exposure to such life events between individuals with different socioeconomic position (SEP) contributes to socioeconomic inequalities in SA. Method: We used 16-year longitudinal data from 2,185 respondents aged 55-85 years in 1992 in the Dutch nationally representative Longitudinal Aging Study Amsterdam. Measurement of SA was based on earlier work, in which we integrated trajectories in 9 indicators of functioning into an index of SA. Using path analysis, we investigated direct and indirect effects of parental and adulthood SEP as well as of self-reported childhood and adulthood life events on SA. Results: Almost all included life events had negative direct effects on SA. Parental SEP had no direct effect on SA, whereas adulthood SEP had. Higher Parental SEP increased the likelihood of parental problems and parental death in childhood, resulting in negative indirect effects on SA. Higher adulthood SEP had both positive and negative indirect effects on SA, through increasing the likelihood of divorce and unemployment, but decreasing the likelihood of occupational disability. Discussion: SEP and particular stressful life events are largely, but not entirely independent predictors of SA. We found that high and low SEP may increase exposure to particular events that negatively affect SA. Findings suggest that low (childhood) SEP and stressful life events are interrelated factors that may limit individual opportunities to age successfully.

This research discusses the utilization of Instagram as a means of promoting and preserving Javanese culture on the Instagram account of bpnb diy. The aim of this research is to understand the utilization of Instagram as a tool for promoting and preserving Javanese culture on the bpnb diy Instagram account and to comprehend the supporting factors and barriers to its utilization. The research method used is descriptive research with a qualitative approach. The data collection techniques include observation, interviews, and documentation. Data analysis techniques utilize Miles and Huberman's analysis, consisting of three stages: data reduction, data display, and conclusion drawing. The research results indicate that bpnb diy, has effectively utilized Instagram as a means of promoting Javanese culture. The activities conducted include: Uploading Javanese cultural content. Collaborating with cultural communitie. Organizing contests and thematic events. Using relevant hashtags. The impact of this promotion includes an increase in the number of cultural enthusiasts, as evident from the number of followers, comments, and Instagram insights. However, there are challenges faced, such as a lack of understanding of how to use Instagram effectively, inactive participation from the community, and a shortage of creative resources. Proceeding SYLECTION ISSN 2964-2817 Volume 03, No 01, pp. 819-830 Riki afriandi & Eka Anisa people . Flew & Iosifidis explained that some of the impacts of globalization can be seen from the easier it is for western values to enter Indonesia both through the internet, television media, and print which are widely imitated by the community. This is reflected in the waning appreciation of local cultural values that give birth to lifestyles, such as Individualism . One of the cities rich in art and culture in Indonesia is the city of Yogyakarta. The city is also known as the city of students. There are many quality universities nationally so that many attract students from outside Yogyakarta to study in this city. So that there are so many students or students who come from various ethnic groups and different cultures. Buddhayah is the plural form of buddhi , the cultural sense or culture derived from Sanskrit is related to human mind and reason. Latin Colere in explaining that culture which in English means culture is processing or doing. It can also be interpreted as cultivating the land or farming. The word culture is also sometimes translated as "culture" in Indonesian . Balai Pelestarian Nilai Budaya D.I. Yogyakarta is a cultural heritage preservation center located in Yogyakarta, Indonesia. It is a unit under the Directorate General of Culture of the Ministry of Education and Culture of the Republic of Indonesia. BPNB D.I Yogyakarta aims to preserve and promote the cultural heritage of Yogyakarta and its surrounding areas. Instagram was first developed in San Francisco by Kevin Systrom and Brazilian Michel "Mike" Krieger when they both chose to focus on creating a multi-feature "HTML5 check-in" app in the Burbn project for mobile photography. On March 5, 2010, Systrom finally closed the $500,000 grant he received from Baseline Ventures and Andreessen Horowitz . Josh Riedel then joined Systrom's company as Community Manager. One of her colleagues, Shayne Sweeney, joined in November 2010 as an engineer and Jessica Zollman was hired as a Community Evangelist in August 2011. In January 2011, Instagram added a "hashtags" feature to help users find photos that were similar to each other. This hashtag feature became known as "tags". Instagram also encourages users to create specific and relevant tags when publishing their photos. On February 2, 2011, it was announced that Instagram raised $7 million from various investors, including Benchmark Capital, Jack Dorsey, Chris Sacca , and Adam D'Angelo. Under the deal, Instagram is said to be worth about $25 million. On April 3, 2012, Instagram for Android was finally released. The app was downloaded more than one million times in less than a day. That same week Instagram raised $50 million from venture capitalists to share the company, a process that sent Instagram's value up to $500 million. Instagram's rapid rise was also seen when the following three months Instagram received more than one million ratings on Google Play. Instagram became the fifth app ever to reach one million ratings on Google Play. The gold deal came to Instagram at a time when an acquisition offer came from Facebook, with an offer to buy Instagram for about $1 billion in cash and stock in April 2012. This offer comes with a policy to let Instagram remain independently managed. Britain's Office Of Fair Trading approved the deal on August 14, 2012, followed by the closure of an investigation by the Federal Trade Commission in the United States on August 22, 2012 allowing the deal between Instagram and Facebook to continue. The agreement was finally official on September 6, 2012. Instagram comes from the meaning of the entire application, the word "insta" comes from the word "instant", like a polaroid camera which in its time was better known as "instant photos" . Social media with the concept of social sharing can also display photos instantly like polaroids in its appearance. As for the word "gram" comes from the word "telegram", where the way telegram itself works is to send information to others quickly. Similarly, Instagram can upload photos using the internet network, so that the information submitted can be received quickly . Based on the opinion Helianthusonfri in his book Instagram Handbook said Instagram social media is a social media that has services only uploading images / photos and uploading videos to be published to both Instagram social media accounts themselves or other social media such as Facebook, Twitter, and so on marketing medium. Through Instagram, goods / services are offered by uploading photos or short videos, so that potential customers can see the types of goods / services offered . Promotion is designed to sell a product, promotion is communication carried out by marketers and customers, promotion consists of five types, namely: Advertising , sales promotion, public relations, personal sales, direct marketing. From the various promotions above, this study only focuses on the desired promotion. The desired promotion is to want to achieve certain achievements, get the information well and get the desired feedback . Promotion is a communication between sellers and buyers that comes from the right information that aims to change the attitude and behavior of buyers, who previously did not know to know so that they become buyers and still remember the product . Promotion comes from the word promote in English which is interpreted as developing or reminding. This understanding when connected with the sales field means as a tool to increase sales turnover. Promotion is a variable marketing mix that has a role in an effective marketing strategy. The variables used are summarized in 4p . George & Belch defines social media as a group of Internet-based applications built on Web 2.0 ideas and technologies that enable the creation and exchange of user-generated content. Social media is an umbrella term for Web-based software and services that allow users to gather online to exchange ideas, discuss, communicate, and participate in all forms of social interaction. The interaction carried out can be in the form of text, audio, images, video and other media carried out either individually or in any combination . This can involve creating new content; recommendations and sharing of existing content; review and rate products, services, and brands; discuss the hot topics of the day; pursue hobbies, interests, and needs; sharing of experiences and expertise that in reality, almost anything can be distributed and shared through digital channels. Be it government agencies, ministries, Non-Governmental Organizations , Grahanm & Avery organizations Risa, stated that social media changes the way an organization communicates with its community and the government is not exempt from public pressure to use it. The phenomenon that occurs today is that there are many communities, organizations, or agencies that share information and communicate with other social media users as a form of performance transparency, conveying important information to educate the public, as well as socializing existing programs. Most use official social media accounts because with official accounts the information submitted is certainly valid and easy to interact with users who are followers of non-government, communities, and so on. Some examples of social media platforms that are often used as official accounts are YouTube and Instagram . NapoleonCat is a social media marketing analyst company based in Warsaw, Poland. The company reported that until November 2019, the number of active Instagram social media users in Indonesia increased by 22.6 percent, reaching 61 million users. Almost a quarter of Indonesia's total population are Instagram users. The number of Instagram users in Indonesia with the female gender is more dominant. It was recorded that the number reached 50.8 percent. While male users are only 49.2 percent. The most Instagram users come from the age range of 18 years to 24 years, with a total percentage of 37.3 percent or around 23 million users. In this age range, female Instagram users are still dominant with a percentage of 19.5 percent compared to men who are only 17.9 percent. The second largest users were in the age group of 25 years to 34 years, with a percentage of 33.9 percent. Contrary to the previous age group, this age category is actually superior to male users at 17.9 percent, while female users are only 16.1 percent. The lowest category of users is around the age of 65, which is only 1.6 percent. In the previous research entitled ''Utilization of Youtube and Instagram Social Media as a Means of Cultural Preservation and Tourism Promotion of Kraton Jogja'' Kraton Jogja in using its two social media platforms, especially platforms related to visual and audiovisual, by utilizing various features on Instagram and YouTube. Almost all features, both old features and the latest features, are always used to produce content. Furthermore, this account is always active on both platforms. On Instagram itself the intensity of activity can be said almost every day, this is shown by what is uploaded into the feed and Instagram story. The two studies entitled "The Use of Instagram Social Media as a Culinary Business Marketing Media in Online Communities @deliciousbali" researchers concluded, Context and Content focus on attractive displays to get attention and also pay attention to the combined content of existing text and images and represent what is informed to the recipient of information. The Context and Content aspects that are fulfilled in this case can be seen from how @deliciousbali pay attention to uploading photos, videos and writing interesting captions. Communication establishes interaction, in this case interaction between admin and followers. The interaction built so far is a positive interaction with the active admin @deliciousbali provide answers to questions asked by followers through the comments column. The three studies entitled "Utilization of Instagram Social Media as a Promotional Media to Increase Social Engagement at Bintoro Coffee Shop" researchers found that Training Activities on the Utilization of Instagram Social Media as a Promotional Media to Increase Engagement at Bintoro Coffee Shop have provided several benefits. The perceived benefit is the increasing ability of Kedai Binkop in editing IG Story and IG Feed using Canva. Then the increasing ability of Kedai Binkop in social media marketing strategies. This training resulted in three IG Stories and four IG Feeds that were used as Instagram content. In addition, it can be seen from the results of Instagram Insights that there is a significant increase in accounts reached and accounts that interact during the last 14 days of training. The limitation in this devotion is the lack of supporting facilities such as Zoom Pro and Canva Pro, less conducive training grounds, and lack of participants. Furthermore, for future service plans, video editing training can be carried out at the Binkop Coffee Shop in order to create even more interesting Instagram content. --- Method The type of research that researchers will use is qualitative research that explains the phenomenon profoundly . explained that the qualitative approach is a process of research and understanding based on methodology that examines a social phenomenon and human problems. The research method used is the descriptive method. That is, the author provides an overview of the conditions, situations that are the subject and object of research. --- Result and Discussion Culture is a thing that is passed down from generation to generation. For this reason, it is necessary to preserve culture so that culture is not lost in society. BPNB DIY is one of the institutions that is active to preserve Javanese culture of Jogjakarta. And innovate by using social media in the form of websites, Instagram, TV, etc. In this study will discuss how BPNB DIY conducts Javanese cultural preservation activities in Jogjakarta consisting of Jogja batik, dance, culinary, shadow puppet art, traditional ceremonies, karawitan music art, cultural attractions and others. The following are efforts to preserve Javanese culture carried out by BPNB DIY through Instagram social media. --- Presenting the Results 1) Content packaging in @BPNB.diy Instagram now has various features to upload various content. The @BPNB.diy account takes advantage of various features available on Instagram. Such as reels, feeds, instastory. The use of existing features will be adjusted to the situation and conditions promoted. The goal is that uploads in the @BPNB.diy account have a high enough engagement value and can right on target. If the @BPNB.diy account is promoting an event or a Javanese culture that has more value if it shows the surrounding conditions and content processing activities with cultural themes . Then the feature used is reels. Through this feature, the culinary conditions and conditions are depicted through videos with a duration of 30 seconds and can be accompanied by additional music. The addition of music can add to and support a culture that is being promoted . If the culture or event being promoted does not have activity and interaction and focuses on that culture, then the feature used is feeds by uploading a photo. While the instastory feature is used to notify users that @dapurbalikpapan account has just uploaded content in feeds and reels. Instastory is also used to upload content that is advertorial and needs to be seen by many people . --- 2) Caption writing in Instagram uploads Although Instagram is a social media that focuses on visuals. Instagram can also facilitate its users to write various writings, additional information and support in uploading content . Through captions, users and content creators both culturally and publicly themed can be creative in conveying the content of promotional messages. In its application @bpnb.diy account. Participate in writing captions in each upload. Generally, promotional messages written by @bpnb.diy are informative explanations about the event or cultural content being promoted . Inaddition, the @bpnb.diy account in writing the caption will include complete and additional information about the event or cultural content that is being promoted. Such as reviews of the event or cultural content that is being promoted, contacts that can be contacted, the address of the event, the time of the event taking place, hashtags that match the upload, and if the event is in collaboration with the community or the individual also has an Instagram account, then @bpnb.diy will tag in the upload . Writing detailed and complete captions about an event or cultural content can be useful as a support for the existing visual display. Because without detailed and complete information, Instagram users can find out and description and more information about the uploaded cultural content . In accordance with the statement of Djafarova & Rushworth states that Instagram can be used as a promotional medium. Instagram is a social media that can be useful as a medium of communication with the public, especially customers because Instagram has another function, which is to facilitate marketing and be able to attract the attention of Instagram users. Instagram as a social media that focuses on visuals. So, the aesthetic appearance of uploads on an Instagram is the initial key to attracting the attention of its users. If users have been interested in seeing the visual/aesthetic appearance of a promoted cultural content. Then, users will read a caption containing detailed information and promotions. Writing detailed captions about the culture being promoted has the function of an information source for its users. Through the addition of detailed information, Instagram users Can know clearly and have a deeper picture of the culture being promoted. --- A) Conduct cultural seminars Webinar stands for web seminar, which is a seminar or learning activity carried out online through an internet-based website or application. This seminar technique allows participants from various places to follow the event online. Webinars can be done in various forms, such as presentations, discussions, workshops, and so on. Webinars can also be attended by participants from various walks of life, both academics, practitioners, and the general public. In the webinar, participants can interact with resource persons through the features provided, such as chat or question and answer. Webinars are becoming increasingly popular in the digital age because they are effective and efficient in conveying information and can reach participants from various places . Webminar art culture path spice java Seminar is one of the efforts to provide teaching to the community through discussion and delivery of material. On November 4, 2020, a webminar was held through the zoom application by BPNP DIY in collaboration with the Directorate of Javanese Cultural Development and Utilization. This webminar was carried out online by inviting several resource persons to provide material in accordance with the ability and capacity of the speakers. The first is Dr. Sri Margana, an academician from the faculty of cultural sciences UGM . The second speaker was Danang Swastika, a practitioner of Javanese culture. The third speaker is sinarto s. Bpnb diy invites speakers to be able to provide their material during the covid-19 period. At this time, it was difficult to carry out discussion activities due to the Covid19 outbreak, but bpnb still carried out and avoided direct contact so that the seminar was carried out online. This activity was carried out online and received a good response from the community. --- B) Use relevant hashtags One of the advantages possessed by an Instagram is that it has a hashtag or hashtag feature. The @BPNB.diy account in each upload will include various hashtags. Generally, the hashtags used are #Bpnbdiy, #kancabudaya. The hashtag #bnpbdiy shows the upload is from Bpnb diy. #kancabudaya is a special hashtag owned by @bpnb.diy and shows that the content and events of the cultural theme have been promoted and become recommendations from @bpnb.diy, while the hashtag is pa; ing widely used by @bpnb.diy account itself is #kancabudaya Kanca Budaya is a term that is often used in cultural activities in Yogyakarta. Based on the search results, Kanca Budaya is a series of cultural events organized by Jayadipuran Culture and Art in 2022 with the theme "Meniti Centhini". Kanca Budaya itself is often used by BPNB DIY on Instagram social media, this hashtag is used to make it easier for Instagram users to find out what activities have been carried out by BPNB DIY --- C) Collaboration with Javanese cultural community BPNB DIY collaborates with one of the radio stations, Rakosa Radio, a radio station based in Yogyakarta, Indonesia. This radio station has a frequency of 105.3 FM and can be listened to online through various platforms such as TuneIn, Online Radio Box, Live Online Radio, Jogjastreamers, oiRadio, and the Radio Rakosa FM Jogja application on the Google Play Store. Rakosa Radio broadcasts various programs such as news, sports, music, and talk shows. This radio station is quite popular in Yogyakarta and has many loyal listeners.in this collaboration activity BPNB DIY conducts a broadcast entitled better know history and culture which in this case will present a presentation about history and culture packaged by colleagues from rakosa radio every 7.30 WIB. --- D) Upload Javanese cultural content On May 20, 2020, when facing the Covid-19 pandemic, BPNP Jogjakarta continued to carry out activities to preserve Javanese Jogja culture by making a kethoprak performance entitled Aja Mulih Disik, Kethoprak itself is a complete folk art, because kethoprak contains various other elements of art. In a kethoprak performance in it there are elements of karawitan, dance, dagelan, tembang, artistic system and even acting art collaborating to play a play.the activity is in collaboration with a kethoprak artist who is an expert in his field, the show just started with the first episode, the activity lasts 12 minutes 45 seconds which was uploaded on BPNB DIY Instagram media so that it can reach all circles. --- E) Holding contests and thematic events Keroncong is a small musical instrument similar to ukulele and Indonesian music style that usually uses keroncong musical instruments. A traditional keroncong orchestra or ensemble consists of a flute, a violin, at least one, but usually a pair of keroncong, a cello in the pizzicato style, a string bass in the pizzicato style, and a singer. The name "Keroncong" probably comes from the rattling sound of tambourines, as heard in background music created by interlocking instruments played on or off the beat. These background rhythms outrun vocals or often slow melodies, and are created, usually, by two ukuleles, a cello, a guitar, and a bass. BPNB DIY held a keroncong competition with the theme of keroncong symphony: In the past, present and in the future, which will be held from May 20 to June 6, 2022, this activity is carried out by BPNB DIY to preserve keroncong culture, and attract spectators who come during the competition --- Create a Discussion The use of Instagram media by BPNB DIY in promoting Javanese cultural content and activities can also be analyzed using The 7C Framework from Rayport and Jaworski.The 7C Framework theory argues that there are seven frameworks in underpinning internet-based marketing communication practices, namely context, content, community, customization, communication, connection, and commerce . What is the application of The 7C Framework in the DIY BPNB promotion process. 1. Contexta. Aesthetics:Instagram display is attractive, layout is well organized and easy to understand. The arrangement of content, both in the form of photos and videos that are displayed is interesting and can attract attention. Functional: The website focuses on existing functions. Based on research by . Context consists of three indicators: language, message content, completeness of information. The conclusion of the context of the toeri 7c Framework is the context that focuses on how technical writing in this case photo captions on the @bpnb.diy Instagram account are clear so that information reaches followers or followers well. 2. The content of the website is a combination of text and images that already represent what is informed to customers. Based on previous research , the content indicator in question is an image or video. The conclusion with the research is that the content display content in the form of photos and videos from the @bpnb.diy account can look professional or known as istagramable so that it gets likes and comments from followers. 3.Community In this framework, an inertation appears on the DIY BPNB account. The interaction between users on Instagram can be seen from several people or communities posting using certain hashtags to make it easier for people to find Javanese-themed content. Community is one of the strengths of Instagram, because both provide features that make it easier for someone to see, search, and share images . 4.Customization In this section occurs in DIY BPNB accounts, Customization is the ability of users to adjust the display as desired and biased to choose what they want to see or not want to see. Instagram is more about utilizing the features that have been provided. BPNB DIY still uses Instagram because of its ability to display content, especially images and videos, more interesting and effective. Especially Instagram whose appearance is intended for visual content. --- 5.Communication The more frequent communication between BPNB DIY and users is through Instagram, either through direct messages or through comments and likes on every BPNB DIY content post. 6.Connection The advantages of social media such as Instagram make it easier for users to manage content. Refers to the degree to which the website can connect with other websites. Based on research by , Maintain and continue to develop relationships that have been carried out and consumers are interested in visiting social media accounts when there are notifications of events. The connection also shows how a social media account can facilitate the reach of speeding up information At one time the posting process can be automatically published or for example when we click the link to find a location, we can immediately be directed to the Google Maps application to find the location. 7.Commerce, Socialmedia used by BPNB DIY has not been able to process buying and selling transactions, its use is only limited to sharing information and interaction. In addition to the seven elements in the 7C Framework, there are supporting and inhibiting factors that also affect the use of Instagram in promoting Javanese culture on this [email protected]. Based on the results of interviews with Instagram managers @bpnb.diy, researchers found supporting factors for the use of Instagram social media on @bpnb.diy accounts, namely the Instagram site is one of the free and popular sites that can be downloaded by everyone, the ease of features provided by Instagram, easy and fast in disseminating information, and wider customer targets. Factors inhibiting the use of Instagram social media on the @bpnb.diy ress account, namely: Not all followers give likes and comments on every upload of the @bpnb.diy account. This is because the time and tastes of other Instagram users are different, so there are some uploads whose topics are less raised, The spread of negative feedback or comments from other Instagram users cannot be prevented quickly. This is because there is only one person who manages a @bpnb.diy account and not every time he sees Instagram and can respond to negative feedback or comments. In addition, @bpnb.diy account managers cannot select other Instagram users' negative uploads or comments to be displayed or not displayed, because the feature does not exist on Instagram. --- Conclusion Based on the results of the study, it can be concluded that the @bpnb.diy account has used promotion through Instagram social media by utilizing Instagram features related to promotion in the form of advertising , public relations , maximizing in doing promotions. In promotional activities from linking the elements of promotion mix above utilizing features from Instagram. As for the use of Instagram in the promotion process, there are 7 features in the form of photo uploads , captions, comments, geotaging, likes, hashtags, and also followers. Based on the results of research conducted by researchers, the Instagram feature plays a big role in every promotional activity. The use of Instagram as a promotional medium makes it easier to spread its visuals to attract attention and interest and affect the greatest attraction for tourists to come and visit and spread about Javanese culture In each feature utilized in the promotion process, researchers associate the promotion mix. Researchers concluded that the use of Instagram as a promotional medium by @bpnb.diy accounts has been done well. In the future, for @bpnb.diy accounts, the four promotional mixes will be better in the promotion process. The existence of features on Instagram adds to the advantage of promoting @bpnb.diy accounts because it is easier and more efficient. This proves that Instagram is an online social media that is very appropriate in carrying out promotional activities.

Indonesian society is a plural society, this can be seen from the diversity of culture, natural environment and geographical area. The diversity of Indonesian society is reflected in various artistic expressions (Khan et al., 2020). Furthermore, it can be said that various community groups in Indonesia are also able to develop their arts typical of their regions, where the arts they develop can be a model of knowledge in society (Donohue et al., 2018). One of the challenges and opportunities of society in cultural development today is globalization. Globalization is a symptom of the spread of certain values and cultures throughout the world. The forerunner of the spread of world culture can be traced from the travels of Western European explorers to various places in this world (Oswald A. J. Mascarenhas, 2019). In essence, in the current era globalization has brought cultural nuances and values that affect the tastes and lifestyles of the people (Anwar et al., 2022). Through an increasingly open and accessible media, people receive various information about new civilizations coming from all corners of the world. Meanwhile, we realize that not all citizens are able to judge where we are as a nation. For example, there is so much new information and culture brought by the media, both print and electronic media that often feel foreign from the 2nd view of life or the norms that apply in Indonesia (Yohana et al., 2020). The ease of accessing all forms of information in the era of globalization related to the rapid development of communication technology allows cultural contact to no longer be carried out through direct physical contact (Rachmawati et al., 2021). So that ordinary cultural contacts, which are physical or individual, begin to shift towards mass cultural contact, which involves a large number of

Zhou, Spinrad, Valiente, Fabes, & Liew, 2005; Thompson & Meyer, 2007) . In short, experiences in the family may have important consequences for an individual's future close relationships such as marriage. Accordingly, the goal of the current study is to evaluate the long-term significance of positive-engagement behaviors in the family of origin. Positive engagement refers to an interpersonal style characterized by transparent communication, warmth, and support . It entails conflict-resolution strategies that emphasize clear communication and cooperative problem-solving. In the present analyses, we evaluate the extent to which overall levels of positive engagement in adolescents' families of origin, as well as adolescents' unique expressions of positive engagement in observed family interactions, statistically predict these individuals' marital outcomes approximately 20 years later when they are adults. The present work is informed by the Development of Early Adult Romantic Relationships model . Of particular relevance, the model posits that the interactional characteristics of families influence the younger family members' later competencies in intimate relationships . Bryant and Conger presented three routes through which behaviors in the family of origin may additively combine to affect later relationship outcomes: observational learning , socialization , and behavioral continuity . The observational learning perspective asserts that individuals imitate patterns of interpersonal behavior that were modeled and reinforced most frequently in their families of origin. The socialization perspective proposes that interpersonal patterns are acquired via the individuals' direct interactions with either their parents or their sibling during adolescence. Finally, the behavioral continuity perspective states that individuals' interaction styles in adolescence persist into adulthood because they help to shape the environmental circumstances that individuals are exposed to across the life span . Whereas the first two mechanisms suggest that exposure to familylevel dynamics contributes directly to outcomes in later romantic relationships, the latter implies that such outcomes are due to the stability of individuals' interaction styles across the life span. In an early test of the DEARR model, Conger, Cui, Bryant, and Elder evaluated whether behavior among family members from adolescents' families of origin predicted warmth in those adolescents' early-adulthood dating relationships . This study used a subset of data from the Iowa Youth and Families Project , a large ongoing longitudinal study of development from early adolescence to adulthood. Conger et al. found that observed levels of nurturing parenting by the adolescents' mothers and fathers were positively associated with the adolescents' expressions of warmth towards their dating partners during emerging adulthood. These effects held when controlling for qualities observed in parental marital interactions . The Conger et al. findings suggest that observed family interactions are related to future competencies in romantic relationships. However, the behavior observed in family interactions may reflect family-level, relationship-specific, and/or individual-level processes . Therefore, an important next step is to clarify which of these processes account for associations between family-of-origin interactions and later experiences. The Social Relations Model provides a methodology for quantifying the relative importance of each of these processes. We recently revisited the IYFP data from 1989 to 1991 and used the SRM to partition the variation in positive engagement behaviors in family interactions . In these analyses, we found that variability in positive engagement behaviors between family members was primarily a function of the family climate and individual differences . This pattern of systematic variation suggests that family-level and individual-level factors are most likely to predict subsequent behaviors in adulthood. Previous research has uncovered associations between children's treatment by their parents and their future adulthood outcomes. In SRM terminology, the unique aspects of parent-child interactions are called relationship effects. However, our research found little evidence of variation in relationship effects for positive engagement between parents and their children. Instead, parents' positive engagement behaviors with their children were mostly a function of the family mean and the parents' actor effects. This suggests that the overall family climate may be responsible for at least part of the association between expressions of positive engagement in parent-child relationships and later outcomes in adulthood. The research presented here uses insights from Ackerman et al. to extend Conger et al.'s findings much farther into adulthood. In doing so, we use the analytic framework provided by the SRM to derive our primary predictor variables. The majority of the focal individuals whose dating relationships were studied in Conger et al. are now husbands and wives in their early thirties. Thus, we can examine whether behavioral patterns in the family of origin are carried over to the adult role of marital partner. In addition, we can disentangle the effects of the average expression of positive engagement in the family of origin from adolescents' dispositional expressions of positive engagement. This allows us to quantify the relative contributions of family dynamics and behavioral continuity processes linking positive engagement in an adolescent's family interactions to his or her subsequent marital behavior . Evidence for the plausibility of either process would be indicated by the presence of a statistical link between the corresponding operationalization of the family-of-origin process and later marital outcomes. Because the DEARR model presumes that these processes should operate in an additive manner, however, evidence supporting one process does not necessarily rule out the operation of the other. Finally, because we have observational and self-report data from the focal adolescent's spouse, we can evaluate whether the family-of-origin experiences for the focal person are associated with relationship outcomes for her or his spouse. --- Method Participants Data were drawn from approximately 400 families participating in the IYFP . The project began in 1989 when focal participants were recruited in the 7 th grade . All families in this initial sample were Caucasian, resided in Iowa, and included a father, a mother, the focal individual, and a sibling who was within four years of age of the focal individual. The primary predictors in this paper are based on family-oforigin scores for positive interpersonal behavior derived from videotaped conflict-resolution interactions that occurred during each of the first three years of data collection . The primary outcomes for this paper are based on data from a single wave of interviews conducted during 2007 and 2008. Outcomes include the marital behavior and reports of relationship satisfaction from the 288 focal individuals that were married at this wave of data collection. 1 Focal individuals' ages ranged from 30 to 33 years , and their spouses' ages ranged from 23 to 53 years . Of the 288 focal individuals, 56.3% were women and 83.7% reported being parents. --- Procedures and Measures Family-of-origin sample-In each of the first three waves of data collection , the focal individuals were observed with three other family members as they engaged in a 15-minute conflict-resolution task that was videotaped. Family members discussed issues that caused conflict within the family, with the goal of finding possible resolutions. Independent coders evaluated these interactions on five indicators of what we term positive engagement using the Iowa Family Interaction Rating Scales : listener responsiveness, assertiveness, prosocial behavior, effective communication, and warmth/support. Each rating was made on a 5-point scale that ranged from 1 to 5 . Coders provided a score on each dimension for every dyadic combination within the family, resulting in 12 scores for each indicator. For example, coders rated the focal individual's effective communication toward the father , the mother , and the sibling . Likewise, separate ratings were provided for the other dyadic combinations: FM, FI, FS, MF, MI, MS, and SF, SM, SI. A composite score for positive engagement for each of the 12 dyadic combinations was computed by averaging across the five rated dimensions. Following the logic of the SRM and based on results in Ackerman et al. , our two key predictor variables were created from these dyadic scores. To provide a conservative test of the family dynamics path, we computed the family mean omitting any scores involving the focal individual. Thus, the family mean was the average of the FM, FS, MF, MS, SM, and SF scores. 2 The individual's actor effect, representing the focal individual's unique tendency to be engaged with all of his/her family members over and above the family mean , was computed by averaging the positive engagement expressed by the focal individual towards his/her family members , adjusting this value to control for the fact that the focal individual never has him or herself as a partner , and then removing the family mean to provide an estimate of the focal individual's unique expression of positive engagement that is not confounded with the normative level of positive engagement in his/her family . These variables were computed for each of the three waves and then averaged across waves. 3 Married Sample-From 2007 to 2008, married focal individuals and their spouses completed self-report questionnaires measuring conflict and relationship satisfaction, and they engaged in a 25-minute videotaped interaction task in which they discussed qualities of 1 Focal adolescents who were married were not significantly different from those who were not married on the family mean, t = 0.74, p = .461. Focal adolescents who were married were also not significantly different from those who were not married on the actor effect, t = 0.66, p = .511. 2 The pattern of results with the individuals' behaviors included as part of the family mean were very similar and are available upon request from the first author. 3 The six dyadic scores for positive engagement were used to compute the alpha for the modified family mean at each wave: wave 1 , wave 2 , and wave 3 . The three scores depicting the focal individuals' expressions of positive engagement towards their mothers, fathers, and siblings were used to compute the alpha for the individuals' actor effects at each wave: wave 1 , wave 2 , and wave 3 . Stability coefficients for the modified family mean from 1989 to 1991 ranged from .27 to .39; stability coefficients for the individuals' actor effects from 1989 to 1991 ranged from .27 to .41. Note that analyses conducted separately by wave yielded largely similar results. their romantic relationship , problems in their relationship, and future plans. The self-reported Negative Behavioral Interactions questionnaire included eight items assessing the frequency of negative interpersonal behaviors during the past month. Sample items included "Get angry at him/her" and "Criticize him/her or his/her ideas." Ratings were made on a 7-point scale and were scored such that higher scores reflected more negative interactions; average scores were computed for focal individuals and their spouses . The Quality of Marriage Index assessed participants' satisfaction with the marriage using a 5-point scale . Example items included "We have a good relationship" and "Our relationship is strong." All items were reverse coded and composites were computed by averaging across the five items, such that higher scores indicated greater marital satisfaction (Individuals: α = .96; Spouses: α = . --- 97). Videotaped interactions between focal individuals and their spouses were rated by trained coders on scales from 1 to 9 using the same five positive engagement dimensions used in the family of origin. Composite scores of positive engagement for the focal individual and his/her spouse were generated by taking the average of their corresponding five dimensions . Coders also rated the degree to which focal individuals and their spouses expressed hostility, angry coercion, and antisocial behaviors towards each other, and the mean of these three dimensions was used to create an index of behavioral hostility for the focal individual (α = . 87) and spouse . --- Results Table 1 presents descriptive statistics for the study variables. Altogether, four marital outcomes were assessed for focal individuals and their spouses: observed positive engagement behaviors; observed behavioral hostility; self-reported frequency of engagement in negative interactions; and self-reports of relationship satisfaction. Multilevel modeling analyses were used to evaluate how well positive interpersonal behavior expressed by adolescents and their family members in 1989 to 1991 predicted the adolescents' interpersonal outcomes around 20 years later. We used MLM because the focal individuals' and their spouses' outcomes were substantially correlated . Two predictor variables were included in the primary analyses: the focal individuals' unique interpersonal style during adolescence , and the overall family climate . Note that unlike many dyadic analyses in which both partners supply data for the predictors as well as the outcomes , in the current analyses we only had predictor information from the focal individuals. Table 2 shows the MLM results. As can be seen, the family mean and the individuals' actor effect were both significant predictors of individuals' expressions of positive engagement in their marital relationships. Moreover, these effects were also significant predictors of the spouses' positive engagement . Thus, there was evidence to support the plausibility of both family dynamics and behavioral continuity processes as explanations for an association between family-of-origin positive engagement and later positive engagement behavior in romantic relationships. Table 2 also shows that focal individuals who came from families characterized by higher positive engagement expressed less hostility towards their spouses and their spouses displayed less hostile behavior towards them. This same pattern extended to questionnaire reports of negative behaviors in marital interactions. The family mean also statistically predicted greater relationship satisfaction for both partners. Finally, the individuals' actor effect predicted their spouses' relationship satisfaction as well. In sum, these results show that positive interpersonal behavior in the family of origin is associated with functioning in committed romantic unions across substantial intervals of time. 4 --- Discussion The present study assessed the degree to which observed expressions of positive engagement in individuals' families of origin statistically predict characteristics of their future adult marital relationships. At a most basic level, our findings highlight the association between an individual's positive family climate during adolescence and the quality of his or her subsequent marriage. The current results are therefore consistent with the DEARR model with respect to the developmental significance of experiences in the family of origin. Although the DEARR model specifies that two mechanisms -observational learning and socialization -underlie the connection between exposure to family dynamics in the family of origin and later relationship outcomes, the current analyses cannot definitively distinguish between them. Indeed, we believe that these two mechanisms are unlikely to be independent as observational learning is almost certainly a part of socialization. 5 Despite this inability to distinguish observational learning from socialization, we were able to investigate the relative contributions of processes involving exposure to family dynamics in the family of origin and those related to behavioral continuity in the statistical prediction of marital outcomes. In so doing, we found that family-level factors are related to aspects of adult marital relationships over and above the continuity of individual differences. It is especially noteworthy that the family mean showed robust links with all of the marital outcomes that we examined. This is not to say, of course, that behavioral continuity processes were not in operation. Indeed, the current study also provides evidence for the continuity of individual differences given that the actor effect for the focal adolescent predicted some of the relationship outcomes we investigated. In particular, there was an association between the focal individuals' unique family-of-origin expressions of positive engagement and the degree of positive engagement that they exhibited towards their spouses 20 years later. This finding converges with other research demonstrating continuity in interactional styles such as shyness and explosive temperaments . The current results extend this literature by using observational data to measure the continuity of positive engagement behaviors. Perhaps one of the most striking results from this work was that a positive family climate during adolescence for one partner is associated with marital outcomes for the other partner. Recall that the family climate variable does not include any data from the focal individual. Therefore, it is somewhat remarkable that it was correlated with the behavior and satisfaction of that individual's spouse approximately 20 years in the future. Individuals who grew up in warm, supportive, and engaged families expressed more positivity and less 4 We performed additional analyses to investigate whether the gender of the focal individual moderated any of the effects of the family mean or the individual's actor effect on the outcome variables and found no evidence of such moderation. 5 One particular debate concerns whether marital discord itself is related to adult relationship dynamics above and beyond parent-child interactions . To evaluate this possibility, we included an additional variable in each of our analyses that reflected the average of the Mother-to-Father and Father-to-Mother relationship effects from 1989 to 1991. This variable representing the unique elements of the marital relationship as defined by the SRM did not predict many adult relationship outcomes. However, there was one exception: focal individuals who came from families in which their parents were especially positively engaged had spouses who reported less frequently engaging in negative behavioral interactions with them. This finding is somewhat surprising given that the parental marital relationship should predict the targets' outcomes rather than the spouses' outcomes . negativity towards their spouses, and their spouses did likewise. It is possible that family dynamics foster a supportive interpersonal style that later evokes similar behavior from a spouse. Alternatively, individuals who grew up in families with a positive and warm climate may have sought out partners who provide a similar relationship environment. We suspect that both selection and evocative processes may account for the connection between one individual's experiences in her or his family of origin and a spouse's thoughts, feelings, and behaviors. Investigation of these possibilities constitutes an important direction for future research. Despite our use of a multi-method prospective longitudinal design, this study was not without limitations. One limitation was the use of a primarily Caucasian sample from rural communities. It remains to be seen whether the same results would generalize to samples of other ethnicities and geographical locations. Another limitation entails the restriction to families of origin that included a mother, a father, and at least two children. We based the derivation of our predictor variables on results that were observed for families with this structure , and it is possible that single-parent families and other family structures have different interpersonal dynamics. Finally, we must emphasize that this is an observational study and we cannot claim that experiences in the family of origin truly cause later marital outcomes. Experimental evidence would be needed to make such claims. Nevertheless, the temporal ordering diminishes the plausibility of common alternative explanations . Likewise, the multi-method design and the length of time elapsed between assessments makes a sharedmethod variance explanation for the findings less tenable. In sum, past research has consistently shown that growing up in a family characterized by an aversive emotional climate is associated with a host of negative interpersonal outcomes later in life . The current research provides evidence that growing up in a warm, supportive, and interpersonally engaged family is associated with positive marital outcomes for both the individual and his or her partner approximately 20 years later. Thus, the current study provides compelling evidence for the interpersonal legacy of a positive family climate. Means, standard deviations, and zero-order correlations between variables

This research evaluated how well overall levels of positive engagement in adolescents' families of origin, as well as adolescents' unique expressions of positive engagement in observed family interactions, statistically predicted marital outcomes approximately 20 years later. Data for familyof-origin positive engagement were drawn from approximately 400 families participating in the Iowa Youth and Families Project (IYFP) during three waves of data collection from 1989 to 1991. The primary outcomes were based on data from the IYFP in 2007 to 2008 and included marital behavior from 288 individuals and their spouses. Individuals' unique family-of-origin expressions of positive engagement were linked to the degree of positive engagement they exhibited towards their spouses. A positive family climate during adolescence for one partner was also associated with marital outcomes for both partners. Overall, the results suggest that a positive climate in the family of origin may have long-term significance for subsequent interpersonal relationships. Families are often considered an important context for the development of patterns of interacting in future intimate relationships (e.g.,

Street-level practitioners do not provide public services alone. Although many studies have focused on individual practitioners and their behavior, street-level decision-making is increasingly understood as a collective practice . Specifically, recent studies have provided important insights into one of the clearest manifestations of a collective element evident in much of the present-day street-level work: deliberation . Deliberation is a practice in which street-level practitioners jointly explore work problems and discuss possible solutions. This is a topic of importance in research and practice as many street-level bureaucracies have pushed toward increasing cooperation with a variety of peers, both within and across organizations and sectors . Deliberation has the potential to improve the process of street-level decision-making by producing a higher degree of consistency across decisions, by increasing responsiveness and creative solutions for citizens, and by making work more purposeful . Even though deliberation is receiving increased attention, only few studies have closely examined its everyday dynamics. A comprehensive understanding of the situated performance of deliberation-how street-level practitioners actually engage in deliberative practices as part of their everyday work-is still lacking. Recently, Møller took an important first step. She put the spotlight on deliberative routines by showing which routines street-level workers use to reach shared decisions. Although routines are typically taken for granted, we have known for a long time that both formal and informal routines help to structure street-level practices . A more thorough, sophisticated comprehension of routines for deliberation, therefore, would help us to understand the process and organization of deliberation. In this article, we draw on insights from a strand of research on Routine Dynamics Theory, RDT . RDT defines organizational routines as repetitive, recognizable patterns of interdependent actions . Every time a routine is performed, it creates the opportunity for individual variation, and, over time, routines can be subjected to structural changes. This approach provides an analytical lens through which to elucidate the shared sequence of activities of deliberative routines as part of everyday, situated work, so as to contribute to a processual and situated understanding of deliberation. In short, we seek an answer to the question: how and why are deliberative routines performed and developed in particular ways in everyday street-level work? Using the RDT lens, we analyze data from an extensive ethnographic study of child and family services in the Netherlands that includes the observation of 92 performances of a deliberative routine, analysis of policy and organizational documents, and 42 interviews with street-level practitioners, their managers, and municipal policymakers. Our analysis demonstrates the processes through which street-level practitioners practically, creatively, and reflectively use deliberative routines in their everyday work. Contributing to a theory of deliberation, we elucidate how and why a deliberative routine is performed, develops over time, and deviates from the routine design. With this we further develop Møller's recent innovative theorizing in this journal. More in particular, we posit two types of factors that inform how practitioners perform a deliberative routine contextually: their intentions and ends-in-view on the one hand, and seemingly mundane contextual factors like the frequency with which deliberative routes are available, the duration of routes, their physical location, and the relationships among participants orient practitioners' actions on the other. Correcting their image of routines as static, inert practices , we show that street-level routines are used dynamically and potentially reflectively, and that they are likely to be subject to constant change. Our analysis suggests that deviating from an initial design can help street-level practitioners successfully accomplish a routine and their work in general, but that it also comes with serious risks for equal treatment and accountability. Finally, furthering the debate on management of street-level practices, we argue that enabling deliberation is a promising yet complex management practice that requires an ongoing dialogue among practitioners, street-level managers, and local policymakers. In the following section, we discuss the current literature on street-level work and deliberation and argue that there is a need to further expand our understanding of routines in street-level deliberation, specifically regarding the role of deliberation. We then present the research context of child and family services in the Netherlands along with the study's ethnographic research methods, followed by the findings. Finally, we discuss the implications for theory and practice as well as their limitations and conclude by suggesting avenues for future research. --- Theoretical Background Street-level practitioners make an important contribution to policymaking through the discretion they exercise . This exercise of discretion, however, is highly influenced by interaction with peers . In light of this, scholars have recently drawn attention to the role of deliberation in street-level work . Although deliberation can be a cognitive, individual practice in which practitioners balance motivations for a specific service or treatment, in these studies the concept specifically refers to deliberation as an interactive, social practice of exploring and discussing encountered problems and possible solutions among street-level practitioners and others working in street-level organizations. Studies have argued that deliberation helps to diminish experienced uncertainty and provides emotional support . By engaging peers, practitioners mobilize others' knowledge, skills, repertoires, experiences, and perspectives , which helps to filter idiosyncratic judgments, embedded assumptions, and moral dispositions . Practitioners might involve managers to gain a mandate for their actions , or involve peers to "collectivize" responsibility. Another purpose of deliberation is to explicate reasoning, often with explicit reference to legal frameworks and professional knowledge, contributing to the accountability of decisions . Lastly, deliberation serves reflection, an iterative practice that is necessary to develop customized and responsive solutions and improve work practices more structurally . Although several studies have observed the function of deliberation, only few have examined the nature of deliberation in detail. Deliberation can occur in designated meetings or in ad hoc exchanges between peers and can range from very formal to very informal. Whereas formal meetings have the risk of becoming too time-consuming and inefficient, informal meetings can inhibit transparent and accountable decision processes and outputs . Furthermore, the presence of supervisors can endanger "psychological safety" , whereas peers might contribute to the feeling of safety that is needed to discuss alternatives to standard practices. At the same time, peers create social ties and exert social pressure, possibly leading to the exclusion of relevant perspectives and the sustenance of "groupthink" and the collective enactment of injustice . Lastly, the degree of latitude and the nature of autonomy that practitioners experience influence whether they either turn to their existing repertoire and established relationships in an effort to work efficiently and effectively, or are more likely to develop new routines and relationships with other professionals . Several scholars have proposed to-more or less from the top-down-organize deliberation at the street-level to better regulate decision-making. Whereas previous street-level procedures and policy rules aimed to control the outcome of street-level decision-making, peer review and procedures for group decision-making have been proposed to restructure the process of street-level decision-making , perceiving it as an opportunity for new forms of procedural justice . Similarly, Lipsky suggests building peer review and support into the weekly routines of practitioners. Taking those ideas a step further, Møller observes that deliberation is highly routinized and introduces the concept of deliberative routines: "organizational routines that enable deliberation, during which one or more cases are discussed and potentially decided upon." The leveraging of the potential of these "managerial tools," she warns, "require[s] reflexive awareness and skillful orchestration" . Møller and Goldman and Foldy also point to the need to trace deliberation and determine the influence of time, place, and space. Following these suggestions, we extend theories of deliberation and deliberative routines by systematically analyzing a multitude of performances of deliberative routines, demonstrating their situated and processual nature and the role of time and place in their performance and development. This in turn allows us to make additional suggestions for how deliberation can be organized and managed. Long ago, street-level literature uncovered practitioners' routines in the form of informal practices used to cope with everyday dilemmas . Routine activities are said to form the bulk of street-level work, together with ordinary, nonroutine cases which "cannot be handled promptly but fall within the range of situations that street-level bureaucrats are familiar with" . By and large, street-level literature has understood routines in terms of heuristics that enable street-level bureaucrats to cope with the pressures they experience, saving time and cognitive resources. Routines are treated as inert, tacit, unquestioned work activities . Being perceived as "structure" and highlighting their static and "institutionalized" nature, street-level theories have hardly reflected upon the way organizational routines come into being, how they work, how they relate, and how they might change. We draw on RDT in Organizational Theory to better understand the performance and development of deliberative routines. This strand of research puts its focus on shared practices and defines routines as "repetitive, recognizable patterns of interdependent actions, carried out by multiple actors" . By foregrounding actions, this approach draws attention to how "the routinized character of most social activity is something that has to be 'worked at' continually by those who sustain it in their day-to-day conduct" . In the everyday performances of routines lie the possibility for variation or improvisation in response to the specific situation and the specific actors involved . These variations might be necessary to accomplish the same pattern . Yet, variation intentionally or unintentionally might also lead to the production of new or different patterns , possibly deviating from the way they were designed , which we refer to in our study as routine development. With this perspective of routines, RDT offers four important insights for further analysis of the routinized performance of deliberation. First, it draws attention to the dynamic or processual nature of routines, providing insights into how and why routines remain stable or change by looking at the internal dynamics of routines. Second, RDT specifically analyzes routines as situated practice, arguing that "context and routines are mutually constituted as they are performed, enacted, reproduced, and changed" . In this way, RDT draws attention to the material, spatial, temporal, and social features that form the organizational context of the routine and how these inform routine performances and development . Third, a further theoretical contribution lies in its observation that externally defined goals do not determine actors' actions, just as practitioners' intentions and their orientation toward organizational goals also inform routine performance . Actors develop ends-in-view, meaning ends that they have in view in a specific routine performance that are constitutive of their actions . These ends-in-view can be informed by and aligned with the preestablished organizational goals referred to as purposeful action, or they can be directed toward coping with the immediate circumstances unrelated to the preestablished goal or overall, longer-term outcome, referred to as purposive action . Fourth, RDT has demonstrated that each time a routine is performed there is an occasion for reflective talk . This collective reflection might merely concern the mismatch between actions that are needed and the routine-as-designed, thereby justifying the need to adjust actions to meet the circumstances. However, it becomes especially interesting when reflective talk concerns variations in the routine's pattern, its evaluation, and leads to the decision to perform the routine differently in the future . --- Research Context and Methods --- Research Context Within the more general context of increased cooperation and attention to deliberation in the delivery of public services, we should say something about the nature of and current developments in child and family services where this study was conducted. Whereas before 2015 responsibility for different domains of child and family services in the Netherlands was dispersed over three levels of government, as of 2015 the responsibility for the whole continuum of child and family services-ranging from educational advice to child protection, and from behavioral therapy to services for mental or physical disabilities-was integrated and decentralized to municipalities. The decentralization was accompanied by considerable austerity measures. The national Youth Act of 2015 specified that services should aim to be customized, capacitating, integrated, preventative, demedicalized and local. This development does not stand on its own as many European welfare states are undergoing similar developments . Preceded by an extensive collaborative process with government agencies, professional associations, beneficiaries, and other stakeholders, the national policy design included much discretionary space for municipalities and suggested teamwork and collective decision-making to strengthen professional discretion at the local level. Within this larger context, this study was conducted in the municipality of Dunetown and its local Child and Family Center Dunewater . Dunetown commissioned the CJG, which was already responsible for child health services , to provide primary educational advice and assign child and family services either to a specialized provider or to their own primary services . Within CJG Dunewater, approximately 60 street-level child and family practitioners, forming six teams, are responsible for allocating and providing child and family services. Within these teams, practitioners with various disciplinary backgrounds are expected to work together to develop solutions for complex family problems. These practitioners all have a higher professional degree in pedagogical or social services. Their varied expertise ranges from street-corner work, educational advice, child health care, child mental health services, legally mandated child protection, and probation services. Dunewater is an atypical organization, as it has taken various innovative and exceptional measures to promote and legally formalize discretionary room . The practitioners have wide degrees of discretion to allocate customized services, including the legal mandate to allocate services and corresponding expenditures on behalf of the municipality, and few formal procedures or rules for accessibility. There are two types of teams in CJG Dunewater. Team 1 functions as a front office, dealing with questions from families and other professionals. It is also their responsibility to judge requests for support from either parents or other child welfare providers and then allocate appropriate child and family services. Team 2 provides primary educational advice to families. They are responsible for supporting a network of local schools and social organizations so that possible problems are flagged and referred to them at an early stage. When support is no longer adequate or when a school within their network asks for help, they are responsible for allocating child and family services. Both types of teams work in separate offices located in the area in which they work. The teams work independently, with little managerial interference. A team of coaches supports the practitioners. With their university degree in pedagogical science or psychology and work experience, these coaches have ample expertise in the treatment of children and can therefore be consulted for either complex cases or professional development. Furthermore, the coaches are involved in organizational and policy developments. Relatively new, the role of coach was developed to support practitioners confronted with increased discretionary room and demands for customization. All in all, the practitioners at CJG present multiple "traditional" characteristics of street-level bureaucrats, as they are directly responsible for communication with and allocation of services to clients and are faced with budget and time scarcities in doing so. Simultaneously, the practitioners are given considerable discretionary space not only to deal with clients but also to deal with time and budget and they are in the midst of a process of professionalization, all emerging developments in street-level organizations. Given the attention to collaboration and organization within interdisciplinary teams, the goal to develop customized solutions, and the large degree of granted discretionary room in practitioners' work at CJG Dunewater, we expected deliberation to be important for the practitioners. Therefore, this is a well-suited case to explore the situated performance of deliberative routines. --- Generating and Accessing Data This study is based on organizational ethnographic fieldwork . Such fieldwork, with its focus on long-term engagement and its reliance on observation, allows for the study of everyday actions that actors engage in as part of their work practices . Ethnographers observe and analyze the context in which activities are enacted, contributing to an understanding of the situatedness of everyday work practices. Ethnographic methods are specifically apt for analyzing routines and any changes therein, "as ethnographers draw close enough to observe the precariousness of such processes, stay long enough to see change occurring, and are contextually sensitive enough to understand the twists and turns that are part of organizational life …" . Observational data were collected during approximately 300 hours of observation between December 2016 and December 2017. Exploratory conversations indicated that some deliberations were planned and had a formal nature, whereas others were unplanned and informal. Two strategies for observation were therefore employed. The first involved regularly asking the practitioners and managers which meetings were planned and attending and observing those. The second entailed a daily presence at the office to observe the unplanned and informal interactions. Over the course of four months, 16 practitioners from two teams were shadowed during the course of their regular work day. The two teams represented the two different types of teams, opening up the possibility for ethnographic comparison . Such a comparison encompasses looking for possible differences, exceptions, or inconsistencies that could shed light on or challenge possible interpretations of the findings. To understand deliberation as part of the larger work routine, the fieldworker observed phone shifts, house visits and faceto-face meetings with families, interactions with other service providers and schools, and registration and referral practices . The observations were supplemented with dozens of daily informal conversations with those involved to clarify their actions . During observation and informal conversation, detailed field notes were made and speech was written down as much as possible . Policy and organizational documents were analyzed to map how deliberation was envisioned, designed, and organized. In addition, the fieldworker conducted a total of 42 semistructured interviews : 15 with practitioners and 27 with their managers and municipal policymakers . The practitioners who were interviewed were the same individuals that we observed to further grasp the "intentions of" activities that determined the allocation of services in general, and the activities of deliberation in particular. We interviewed every CJG manager and involved municipal policymaker to understand the management of street-level decision-making, the organization of deliberation and registration, and their own participation and role in deliberation. Interviews were recorded and transcribed verbatim. The different data were brought into "conversation" with each other for triangulation and negative-case analysis. Finally, interactive sessions to discuss the findings with the different groups of actors in later stages of the project served the purpose of member feedback . --- Data Analysis Analysis of the data was done abductively, in an iterative cycle between data and theory . Initial analysis began during fieldwork. This first phase consisted of multiple rounds of open and more focused coding . After fieldwork had finalized, we realized that there was a limited understanding of the situated use of deliberation in the street-level theories, so we decided to analyze the data from that point of view. The second phase of analysis started with an initial routine design based on a central policy document. We then analyzed the observation data and identified 92 performances of a deliberative routine. We ordered these performances chronologically and compared the actions that were taken, looking for differences, similarities, and changes over time. Through an iterative process of comparing the different performances, which can be understood as a cross-case analysis , we grouped, refined, renamed, and regrouped the actions that together formed the situated use of the routine and the deviations from the initial routine design. Next, we searched for explanations for the differences between the design and the actual performance. We did this by comparing the two teams and their different deliberative patterns, and by combining the observations with interviews that gave insight into the ends-in-view and other motivations of the practitioners. This went hand in hand with a theoretical exploration of routine dynamics. Finally, we sought to explain how developments came into being. All the while, we engaged in a dialogue in which the second author challenged the fieldworker to think through alternative descriptions and explanations of patterns arising from the analysis . --- Findings At CJG Dunewater, practitioners engage in deliberation as part of allocating child and family services. In the following four subsections, we analyze how deliberation is embedded in an initial routine design spurring its everyday use; how practitioners use the deliberative routine in their work and which five deviations become new patterns-in-use; how two types of contextual factors contribute to the everyday use and deviations from the deliberative routine; and how new routine patterns-in-use develop through two types of processes. Between the first two sections we have included an example of situated use of a deliberative routine. We finish with a process depiction of the performance and development of the routine. --- Deliberation in Routine Design Before we can properly analyze how a deliberative routine is performed and developed in street-level work, we need to understand how deliberation was envisioned and organized at CJG Dunewater. For this, we reconstructed the initial routine design through which deliberation was embedded in practitioners' key practice of allocating child and family services. Allocation is an important part of practitioners' work, as it defines which citizen receives which type of care from whom. To accomplish allocation, CJG Dunewater developed a guideline that includes a description of organizational goals and an organizational routine to be used . The guideline was commissioned and developed by five municipalities in the region at the beginning of 2015, shortly after the CJG had assumed its new tasks and responsibilities. It was developed together with child health care practitioners, child protection practitioners, and general health practitioners and was intended to standardize decision-making in the region and manage expenditures, while contributing to the purposes of the decentralization of child and family services: providing support that is timely, capacitating, collaborative and, where possible, demedicalized and local. Furthermore, an important aim was to promote "demand-oriented customization" in which allocation was not based on indications of whether a family fits existing treatments from existing, contracted providers, but on customization. The idea was that this could be achieved if practitioners start from the question: "What commitment and expertise contribute in this case to capacitating the family to deal with their problems and is, in this situation, necessary to achieve results for the child and family?" . Lastly, central to CJG decision-making is the principle of "three pairs of eyes," in which the practitioner's decision is made with the family and is supported by deliberation with other professionals. Included in the guideline was a "deliberation form" that the CJG developed to achieve and document deliberation, which included a list of topics to be discussed and ample space to write down what was discussed per topic. The routine design for allocation, as suggested in the guideline, consists of five steps: question clarification; deliberation; matching; filling out the deliberation form; and finally registering, referring, and informing the family. In question clarification the practitioners are expected to explore and frame the family's question together with the family. Deliberation involves professional reflection on the case to develop an understanding of what the family needs and what support will help satisfy that, including an exploration of alternative solutions. Through matching, the practitioner chooses whether existing services fit the question and contacts the corresponding provider to check the match and availability. The explicit advice is to do matching after deliberation so as to reflect on what the family needs and not on what is provided. The fourth step consists of filling out the deliberation form. Lastly, the practitioner registers the case in the online registration system, refers the family in the registration system to an internal practitioner or external provider, and informs the family about this allocation . We have displayed the sequence in figure 1. In the guideline, two routes were defined for deliberation. The first route, direct desk deliberation, centralizes interaction between peers. The CJG organized the practitioners in multidisciplinary teams, sharing a general base of professional knowledge and skills, but also having individual expertise. The organization in teams was intended to enable and stimulate regular and on-the-spot deliberation. There was no protocol to indicate which team member to deliberate with or when. The CJG also designed a second initial route, the collective coach conferences, during which the practitioners make use of their assigned coach and several peers. The guideline indicated that the coach had to be involved in complex cases, customized or specialized solutions, and in cases where the safety of the child might be at stake . In addition, shortly after that policy was implemented, the CJG added a third meeting. The access assembly would bring together a municipal policymaker, a manager, a coach, and several expert practitioners to solve and learn from complex cases. This meeting's purpose was to "instigate the learning capacity of the organization" . The idea was that it could be used to discuss and Figure 1 The Initial Design for the Deliberative Routine. decide on novel solutions in specific cases, but also to identify more systemic problems in contracting, regulation, and policy. Scheduled every 2 weeks, practitioners were expected to submit a case and a corresponding request beforehand for the meeting's agenda. With the routine design, CJG Dunewater embedded deliberation-and therewith the possibility to develop customized solutions-into the larger routine. From thereon, the design needed to be put into practice. --- Situated Performance of the Deliberative Routine Online we offer Linda's case . This case illustrates how the deliberative routine works. This case is but one of 92 performances of the deliberative routine that we observed. Analysis of those 92 cases, complemented by interview data helped us expose patterns of routine performance that deviate significantly from the way it was designed. We identify five types of deviations: developing new deliberative routes; combining deliberative routes; blurring steps; limited use of the deliberation form and incomplete documentation; and changing participation in routes. These deviations became the new patterns-in-use 2 years after the guideline was designed. We modeled the situated performance of the routine in figure 2. First, in everyday performances, new routes came into use in addition to the existing direct desk discussion, collective coach conferences, and access assemblies . One of the new routes was the casual coach call , which consists of an informal talk with a coach, often quickly after having received a request. The coach call followed some of the suggestions for collective coach conferences as they were used for the same issues and the coach partly followed the deliberation form. Yet, they were one-on-one, not registered, and brief. Another route that was used was the mobile management meeting , an informal, one-on-one talk with a manager, often performed soon after receiving the request and handled by phone. Generally, the practitioners involved managers when they had doubts or questions about existing regulations and rule-breaking, about financial coverage or contracting, or when there were issues with municipal policymakers. There were no suggestions for when or how to use this route. For another new route, one of the two teams included deliberation about cases in formal team meetings held every week. These team talks were rather similar to direct desk discussions as they only involved peers and were flexible and accessible. Yet, they were different because they included more participants, were more extensively documented, and were conducted within the limited time frame of the meeting. In rare cases, practitioners involved a policymaker in what we call a policy chat . Policy chats occurred mostly when policy or contracting rules were unclear. These chats were conducted by phone or email, were short, and lacked suggestions that guided the interaction. Finally, in some cases the practitioners did not deliberate at all . This happened when there was a freely accessible type of support available and families were referred there without needing allocation. Practitioners also did not deliberate when practitioners from other providers requested an extension of existing treatment. The routes are diagrammed in figure 2. A second deviation from the guideline entails the combination of routes . Many routes were combined with either direct desk discussion or team talk, indicating that practitioners often first deliberated with a peer before deciding to deliberate with an individual coach, manager, or policymaker, or with a collective in which coaches, managers, or policymakers participate . Access assemblies and policy chats were rarely performed as a single route, but tended to be combined . And finally, there were cases that were discussed in almost all routes, sometimes going back and forth between them . Third, in contrast to the way the routine was designed on paper, deliberation was not a clearly demarcated step in the larger routine. The initial design emphasized a clear boundary between deliberation and matching to ensure new solutions would be tried rather than having the practitioners think only in terms of existing treatments and providers. In practice, we observed practitioners blurring these steps because, in part, discussing possible new solutions necessarily entailed knowing which providers and services existed and were contracted, whether they had availability, what specific services entailed to establish a fit, and a possible new solution: stacking existing services. Similarly, practitioners went back and forth between deliberation, question clarification, and registration, while attempting to successfully allocate services in specific cases. Thus, in everyday performances, deliberation was used partly simultaneously and partly in combination with the other steps. Fourth, the deliberation form that was supposed to guide and document deliberation fell into disuse. Although the practitioners themselves believed they applied the deliberation form and felt no need to consult or register it, in practice differences were observed in the extent to which the topics on the form were actually discussed. For example, in Linda's case, the practitioners thoroughly discussed possible contributions and solutions and considered the families' concerns and preferences. However, less explicit attention was paid to their knowledge of effective interventions, costs, and contractual forms. In general, as the deliberation form was not consulted, treatment of the topics became less structured. Only the more formal routes included the making and registration of minutes, including motivations and considerations that were discussed. In others, only the final decision with its motivation was documented. A last deviation was changing participation in the routes. This happened particularly to the access assembly, which the municipal policymaker started to attend less frequently. The policymaker wanted to restructure and decrease communication with the CJG and become less involved in individual family cases, explaining: "I was the main point of contact. Now, I am more distanced. I consult with the management, sometimes join a meeting to discuss complex cases. […] It was too much. It is better now, we have to do it together, think along. We're still searching how to organize it properly" . The five deviations we have identified show a complexification, a simplification, and an informalization of the deliberative routine, in which-at first sight-important elements seem to be lost, including particular perspectives, time to discuss cases extensively, the discussion of specific topics, and proper documentation. The question is why the deliberative routes developed and deviated from the routine design. We teased out various factors that play a role. --- Factors Contributing to the Performance of the Deliberative Routine Several factors emerge from the data that help us understand why the situated performance of the deliberative routine diverged from the routine design. First, practitioners performed the routine in certain ways based on the ends they pursued. The central, organizational goal was the allocation of customized services. The guideline suggested a routine design to enable this goal. Yet, customization implied all kinds of new complexities for practitioners' decision-making which in turn created new purposes that practitioners set for themselves, as ends-in-view. These were sometimes aligned with or related to the complexities of the goal of customization, whereas at other times they were less related to them. Additionally, the routine design did not always contribute to achieving the goal, when aspects were missing or made too complex. A first end-in-view, informed by the goal of customization and consecutive discretionary space, was to make sense of cases in this new and more complex situation, which was different than initially envisioned. Discussing the necessary treatment before considering existing treatments and providers proved to conflict with actual case processing. Practitioners did not start from a "blank sheet," but created an overview of existing treatments and providers, experiences with them, their suitability, and their availability in their discussions with others. A practitioner explains: "In this case, we found that the existing treatments, the existing providers, none of them offered what this boy needed. It was only after establishing this, after this realization, that we started to develop something new" . Also, deliberation, matching, and registration regularly led to demands for a clearer understanding of the clients' needs and situation and possibly also refinement of the clients' questions. Consequently, the order of routine actions as designed slowly became more complex in practice. A second end-in-view that developed in light of customization was to acquire additional perspectives. Additional perspectives allowed them to explore alternative, customized solutions. For example, during a direct desk discussion, the practitioners discussed the possibility of combining treatments for a multilayered request of a family in the midst of an antagonistic divorce, yet desired more expertise to decide whether part of the treatment could be done internally through primary educational advice . Third, customization spurred practitioners to search for a mandate in terms of additional financing and alternative contracting. For this purpose, practitioners often included deliberation with a manager or policymaker at the end of the process. Fourth, practitioners attempted to deal with increased uncertainties resulting from the far-reaching decisions they had to make both for the family and in terms of budget, decisions that often had to be made without clear rules and sometimes even by breaking rules. During one observation, a practitioner confided: "I just got off the phone with the municipality, but the answer remains vague. I'll call [name manager] again, because I don't know what to do with this" . The latter three ends-inview drove practitioners in their performance of new routes and in the combination of routes. Accomplishing deliberation in itself became an end-in-view. The guideline prescribed deliberation, but proved to be an incomplete answer. Managers and policymakers had not yet really settled on the right organization of deliberation either, as illustrated by the managers' participation in informally added routes. This was further aggravated by practitioners' informal deviations that lacked standards to begin with, leading to occasional searches for the proper space to deliberate about specific issues. In their efforts to move things along, they made phone calls until they reached someone who could provide them with a definite answer. Beyond the goals of customization and deliberation, the practitioners were eager to complete the routine in an organized, comprehensive, and timely fashion. One practitioner explained: "I don't really like putting it off for a very long time. I just want to have an answer myself […] I ask my questions to the people I think can provide a normal answer quickly" . Performing the routine in the quickest possible way helped them keep their work organized, as they always had a pending list of allocation requests waiting to be completed. The practitioners also preferred to allocate services timely to help the family without letting them wait. A practitioner explained: "We don't have to do it this quickly. Look, you have six weeks from request to allocation and that is workable. But I don't like to let the family wait. Sometimes it's urgent but even if it's not, I wouldn't want to wait that long for an answer either" . We observed that practitioners often first discussed cases with the team member that was present, asking: "Do you have a moment to think along?" When direct desk discussion did not suffice, they generally preferred an immediate phone call over waiting for the next scheduled meeting. Finally, the timely completion of the routine could also lead to its simplification. The practitioners did not refer to the deliberation form or fill it out, as they believed the questions on the form were already integrated into their everyday performance; "In principle, the questions from the form, we already do that in our conversations. We are already going to fully consider [the questions] whether help has been provided before, has it been good or not, have parents been satisfied with it? […] You know, one way or another those questions, that reflection, is completely within us" . The ends-in-view that influenced the practitioners' exercise of the routine were partly informed by the new requirement to customize and the new requirements to deliberate, combining a prioritization of the client with organizing their work. Other factors that oriented practitioners' performancesand their divergence from the routine design-could be called contextual. These factors included the frequency of available routes, the duration of routes, the physical location of, and the relationships among participants in routes. The end-in-view of a timely completion of the routine was partly informed by the contextual means. For example, Team 2 spent much time outside the office, at families' homes, or in interdisciplinary meetings with professionals from other organizations. They walked in and out of their office and irregularly encountered colleagues for deliberation. For Team 2, the formal team meeting provided a fixed moment to include multiple perspectives in their otherwise physically dispersed work routine. Team 1 used direct desk discussion for the same purpose. As a practitioner from Team 1 explained: "We work in shifts together, so we always have someone in front of us to quickly deliberate with" . In addition, as a coach was often present at the office, Team 2 made use of the casual coach call as a shortcut to reflect or simply fulfill the requirement of deliberation. We often heard a variation on the sentence: "As you are here, can we discuss…?" Team 1 preferred to call the coach on the phone for a quick answer, with the consequence that documentation was limited. Finally, Team 2 rarely used the access assembly because it was held in Team 1's office. Team 2 therefore attempted to solve cases as much as possible through collective coach conferences and only attended the access assembly when it was absolutely necessary, thereby explaining the development of route 5.1. Finally, the participants in specific routes and the relationships practitioners have with them constituted an important means that oriented the performance of the deliberative routine. Peers provided the opportunity to ask for help and created confidence about possible solutions. A practitioner explained: "When I'm in doubt, I always involve a peer. As long as I feel a little bit of doubt, a glimpse, I always deliberate with my peers and that is why it is very nice that you are always in pairs" . Another practitioner said: "We're a small team […] and we're well attuned to each other. There is very little that we don't know of each other. We share things like that" . The deliberations in direct desk discussion or team talk prepared the practitioners to reflect on a case with superiors. The importance of involving peers over other means can also be observed in Team 1's scarce use of the collective coach conference. The practitioners expressed their discomfort with their coach as they felt she disapproved of the issues they submitted. As a result, they preferred to make casual coach calls to other coaches or phone peers from other teams with specific expertise to avoid having to deliberate with their coach. Practitioners' relationships thus contributed to their choices for routes and the combination of routes. All in all, the way the routine was performed and the choices that were made had real consequences for the process through which important decisions on the allocation of services were made. The performance of the deliberative routine along with their deviations was instigated by practitioners' pursuits to make sense, involve multiple perspectives, acquire a mandate, and deal with uncertainty in complex cases of customization. Additionally, practitioners also needed to manage their work load, complete the routine in a timely fashion and simply complete the process and make a decision, all of it importantly guided by contextual factors such as the time, place, and relationships of those involved in the deliberation. --- Patterns and Reflection-on-Action During our observations, several new patterns-in-use were developing, which allowed us to identify and analyze the two processes through which such patterns come into being. In the first process, practitioners deviated from the guideline in specific performances. The specific diversions were repeated in subsequent performances by other practitioners, who were informally yet collectively altering the routine in the process. This happened, for example, with the use of the access assembly. Over time, we observed the decreasing presence of the municipal policymaker, thereby reorienting the practitioners' use. In the beginning, the access assembly was used regularly and it resulted in quick decisions. Slowly, with the absence of the policymaker, cases were routed through policy chats, mobile management meetings, and then back into the access assembly, as decisions failed to be made without the right participants and consecutive expertise and mandate. Practitioners complained to each other and became reluctant to use the assembly. In the following months, practitioners started to refrain from submitting cases. They experimented with using alternative routes directly, which in several cases resulted in quicker decisions. A new pattern of the routine started to develop through repetition and retainment of the deviations. A second process through which new patterns-in-use developed was through collective reflection on the deliberative routine. In these reflections, practitioners talked about specific routine performances and the recurring pattern they had observed, discussing advantages and disadvantages of what was happening and what they did. In these reflections practitioners decided to make changes to the routine, but such changes were not formalized. For example, while discussing cases in team talk, members of Team 2 voiced issues they had experienced, stating: "I can't talk well under time pressure," or "we have to introduce cases carefully" . This led the team to discuss the practice of team talk. Some practitioners argued that the team meetings were already pressed for time and that spending time on deliberating cases might not be efficient. Moreover, they expressed their concerns about the need to properly introduce and discuss the cases and the lack of time to do so during team talk. Although most agreed with both issues, some argued that the plurality of opinions in team talk was very valuable to their work. In addition, by maintaining team talk, the practitioners had multiple opportunities over 2 weeks to deliberate, ensuring a timely answer and not having to "swim in a vacuum" . The issue remained unresolved during the specific discussion but received further attention in the months that followed. In sum, either through processes of deviation, repetition, and retainment, or through processes of reflective talk, practitioners-tacitly or consciously-changed the pattern of the deliberative routine. What is interesting here is the role of CJG managers in these processes. Managers were sometimes participants in the deliberative routes, and in that capacity also participated in the individual and repeated variations of the deliberative routine. This was not translated into a new formal guideline, possibly also due to the absence of managers and policymakers in the collective reflections on routine performances and patterns. At this point, we can take a final step in our analysis by developing a more abstract depiction of how the deliberative routine was performed and evolved. --- A Process Depiction of Deliberative Routines' Performance and Development What we see is that the motivation for street-level practitioners to perform a deliberative routine as part of their everyday work is a routine design . The initial design, as we encountered it, starts with a particular organizational goal and, especially, an organizational infrastructure together with more or less specific guidelines and other artifacts to pursue such a goal. Guidelines, however, are action sequences on paper. Practitioners perform them in a specific context dealing with specific cases. In part, what this means is that practitioners are dealing with tensions between the routine-as-designed and what is feasible in practice. Moreover, it means that practitioners are developing new parts of the routine to better serve the intentions that develop in action, which can be more or less informed by and in line with preestablished goals and the immediate circumstances. Speedier routes in the deliberative routine, for instance, help to better serve the clients and keep work manageable. What was kept separate or offered as alternatives on paper might be combined in practice to deal with complexity and ambiguity, leading to more complicated pathways. Some elements of an original routine might be dropped, as they do not fit into the way work is actually done or just seem purposeless to practitioners. The shaping role of practitioners' intentions and particular ends-in-view are included in figure 3. In dealing with the immediate circumstances, the temporal, social, and spatial contexts guide the modifications . Contextual factors and ends-in-view influence each other. For example, the notion of duration/waiting and physical location of a deliberative route are related to the need to develop a solution quickly, both to keep work orderly and comprehensible and to help families quickly. Our study shows us how new routine patterns emerge. This patterning is often the result of the repetition and retention of specific deviations as changes to the routine. At times, reflective talk about routines plays a part in this process. Reflective talk can be prompted by the situated use itself, or by the newly emerging pattern. It can be part of performing the deliberative routine, or it can get shape outside the time or space of the deliberative routine. Either way, it can be an important force in developing the deliberative routine. Figure 3 The Process of Deliberative Routine Performance and Development. --- Discussion and Conclusion Deliberation in street-level work is increasingly recognized as contributing to shared, responsive and consistent decision-making . It is also acknowledged that how deliberation is performed shapes the outcome of public service delivery . Therefore, it is important to expand present knowledge on the day-to-day performance of deliberation as embedded in the larger routines of street-level decision-making. Although research on street-level deliberation has touched on its temporal, spatial, relational, and purposive aspects, we significantly extend previous research. We do this by asking an important question that had remained partly unanswered: how and why are deliberative routines performed and developed in particular ways in everyday street-level work? Following Møller in focusing on deliberative routines, and making more extensive use of insights from RDT , we elucidate how and why a deliberative routine is performed, how it develops over time, and how and why this deviates from the routine design. Contributing to a theory of deliberation in street-level literature, we posit two types of factors that inform how practitioners perform a deliberative routine in a specific context dealing with specific cases. First, street-level workers make use of the intentions they have and the ends they have in view for themselves or for a particular performance . These intentions and ends-in-view inform how deliberation is performed, quite possibly resulting in particular stable variations of a routine and new patterns of the routine as such. In a particular performance of deliberation, larger organizational goals embedded in the routine design are accompanied by and might compete with goals the practitioners have and which might or might not match those of the organization. More specifically, aiming for customized services has contributed to certain purposeful ends-in-view such as the different sense-making processes, the need for additional perspectives and mandates, and dealing with new uncertainties and ambiguities, besides purposive ends-in-view such as the timely and organized completion of the routine. This explanation goes beyond personal motives, coping, or pursuing predefined goals, rather arguing that intentionality develops in action. Furthermore, it goes beyond either prioritizing clients' needs or saving cognitive and temporal resources, showing how these are intrinsically connected in the ends that practitioners pursue. Second, seemingly mundane contextual factors play an important role in the performance of deliberative routines and in the emerging ends-in-view: the frequency with which deliberative routes are available, the duration of routes, their physical location, and the relationships among participants in routes orient practitioners' actions. Ends-in-view and contextual factors develop in tandem . As deliberative routines are inherently situated, "enacted in and inseparable from their sociomaterial context" , the intentional, temporal, spatial, and relational aspects of everyday street-level work should therefore be carefully considered in the study and practice of street-level deliberation. A second contribution to a theory of deliberation in streetlevel decision-making comprises new insights into how the everyday performance of deliberation-informed by factors uncovered-might lead to deviations from the routine design and possibly to the development of new routine patterns. We identified five deviations: developing new deliberative routes; combining deliberative routes; blurring steps; limited use of the deliberation form and incomplete documentation; and changing participation in routes. Individual variations can, over time, alter the pattern of the deliberative routine. Through repeated performance, street-level practitioners structure the deliberative routine as a patternin-use. This might lead to formal or informal modifications. In addition, new deliberative patterns might also arise as the result of collective reflection . What is interesting to notice here is that most of the recent interest in increased deliberation in street-level work has focused on the way street-level decisions have become the object of group discussion. We argue that the deliberative routines within which decisions are made themselves are reflected upon as well. In sum, the image of routines for deliberation that arises from our observations is a dynamic one. We see practitioners as a group, practically, creatively, and reflectively using deliberative routines to reach an organization's purposes as well as their own, keeping some routine elements intact while structurally altering others. Beyond a thorough, sophisticated understanding of the situated performance and change of deliberation, this study contributes to street-level literature in general by providing a nuanced and complex description of organizational routines in public organizations. Correcting their image of routines as static, inert practices, we show that street-level routines are used dynamically and potentially reflectively, and that they are likely to be subject to constant change over time. Lipsky , for instance, although using the concept of routine extensively, offered little help in understanding the development of routines over time, the emergence of its ends and the dynamics of peer interactions in it. Our in-depth investigation helped us understand street-level decision-making as jointly developed and available walking routes at the street-level. As collective patterns they have a stabilizing effect; yet simultaneously, each time a routine is performed is an occasion for variation, for retention of that variation and thereby new patterning. Looking at routines allows for an analysis of street-level decision-making as shared sets of everevolving action patterns, performed in a particular sequence, embedded and informed in everyday street-level work with its spatial, temporal, and relational aspects. Our active employment of RDT with its emphasis on process dimensions of performing organizational tasks, its consecutive detailed analysis of action sequences, and the resulting potential explanations for why routines develop offers an additional contribution to our understanding of street-level innovation, creativity, or improvisation . Contextual factors and the prioritization of particular ends might shape how practitioners innovate and repair policy. Finally, this study contributes to both street-level deliberation studies and street-level management studies by demonstrating the potential of organizing and promoting deliberation topdown. Embracing certain goals, promoting guidelines and flowcharts, and setting up an organizational infrastructure through the creation of dedicated, multidisciplinary teams and meetings for deliberation all contribute to promoting deliberation as a central part of practitioners' everyday routine. To encourage this, street-level managers and local policymakers should pay attention to the context in which deliberation is to be performed, taking into account the mundane aspects of time, space, and relationships. They should acquire a keen understanding of the everyday routines of their street-level practitioners and the ends that their practitioners have in view when they perform their actions. We can apply these insights to theories of street-level management more generally, which have emphasized the need for managementby-enabling . Recent research indicates that decision-making processes can be structured through professionalization, peer review, and collective decision-making procedures . Even more recently it has been argued that the development of routines could be a management tool . Our insights show the possibilities and complexities of structuring street-level decision-making processes through routine design and highlight the importance of paying attention to the situated and sequenced nature of street-level actions. We would also like to point to the need for regular dialogue as a vital element of management-by-enabling. Increased discretionary room and an emphasis on deliberation depend on local policymakers, street-level managers, street-level practitioners, and governed publics to frequently interact to demarcate the playing field and help to make routines run smoothly. This can be facilitated by organizing a periodic dialogue in which relevant actors diagnostically reflect, monitor, and adjust the elements that structure street-level work. By doing so, systemic problems in street-level work can be detected early and change can be initiated in local policy procedures, organizational structures, routines, and accountability requirements. In turn, scholars of street-level decision-making need to pay more attention to the interactions between street-level practitioners on the one hand and local policymakers and street-level managers on the other to better grasp and develop theories of management-by-enabling that allow for street-level creativity and improvisation in their everyday deliberation. Situated performances of and changes to a deliberative routine have consequences for the actual shape of policies. We know from the literature that deliberation helps to diminish experienced uncertainty and provides emotional support , filters idiosyncratic judgments that are embedded in assumptions, and moral dispositions , and has the potential to fuel the development of customized and responsive solutions . Applying these existing insights to our analysis makes us wary that the choice for a certain route might enhance but can also inhibit the positive effects of deliberation. Deviations in the performance of deliberative routines could lead to feeling social pressures , to falling back on existing repertoires and relationships , or to excluding relevant perspectives due to professional turf wars, ignorance, conformity, and groupthink . Specifically, the exclusion of racial, gender, class, or ethnic perspectives might create serious risks for the equal treatment of already vulnerable citizens . In addition, the choice for informal deliberative routes obfuscates how decisions have come about, who has been involved, and whether a thorough discussion has been part of the decision-making process. And lastly, the deliberative processes and the necessary work to maintain them comes with emotional work of its own, possibly creating new uncertainties for practitioners . To understand how practitioners deal with emotions and social pressures, relationships with peers are important to further look into. It is well possible that the long-term development of relationships and identities among peers and between peers and managers plays a role in the patterning of routines over time, but our data do not allow us to confirm or deny this. The risks and high probability of practitioners deviating from routine design for deliberation raises questions regarding the extent to which we can or should trust practitioners to organize their own work and make customized decisions. Discretion has important responsive potential, while inhibiting discretion has proven complex and has often had perverse effects of hidden, invisible street-level practices and outcomes . Our analysis of the intentionality of routine performance shows that predefined goals cannot simply be imposed to orient practitioners' actions. Therefore, we do not argue for less discretionary room to prevent the risks of routine change that we mentioned above so as to achieve more equal, more purposeful, or more accountable street-level actions. Rather, we believe that practitioners' discretionary room should be structured and managed to prevent its own perverse effects. Creative, collective discretion both in customized decisions and in the organization and repair of work processes requires managers to devote ongoing attention to it, and to engage in a constructive dialogue with their street-level colleagues. Furthermore, granting discretionary space is not without obligations and we should look into ways to realize better registration and documentation practices by practitioners, whether they enjoy much discretionary room or not. In bringing about better registration and documentation practices, we need to take into account not only the purpose of procedural accountability, but also look into how it aligns with and can contribute to practitioners' intentions. Effective registration has the potential to simplify practitioners' work when it serves as a mnemonic device or even to make practitioners' work meaningful, for instance when it prevents clients from having to tell their story to many different care providers. The further structuring of practitioners' routine change, forms of creative discretion, and registration practices requires additional research. --- Limitations and Suggestions for Further Research This ethnographic case study of child and family services in the Netherlands has allowed us to observe the situated performance of deliberation in everyday work. Through participant observation over an extended period of time, combined with interviews and document analysis, we mapped patterns and variations, purposes and ambiguities of how a deliberative routine was brought into being and changed. This study and its design, however, have a number of limitations. We observed 92 performances of routines, allowing comparison between them, but all these performances occurred within one organization, within a specific type of street-level work, and within specific local and national contexts. Our findings can therefore be insightful for other cases, but their transferability depends on similarities and differences within other research settings . Child and family services in the Netherlands are in the midst of an important transformation, having been decentralized recently. Pursuing customized services, deliberation became a central element of street-level decision-making, for which child and family services in the Netherlands provided a wellsuited case to explore the situated performance of deliberative routines. The practitioners' professional background made them familiar with peer review and casuistry, possibly spurring their embracing of deliberation. Local characteristics such as the relative independence of and minimum overview by managers and the relinquishing of many of the standardized procedures have contributed to quite large degree of freedom to deviate from the initial routine design and develop new patterns, for which we expect this to be a relatively atypical case. Yet, as cooperation with a variety of peers across organizations and sectors and the customization of public services seem to increase across contexts, and as deliberation among street-level practitioners is ubiquitous, we believe our findings do have relevance well beyond our case. The question remains, then, how exactly deliberative routines are performed and developed in other settings. We therefore encourage additional, comparative research in other local settings, other domains, and other countries to expand our knowledge of the processes comprising deliberative routine performance and development. Although it might take different shapes, we expect that in other settings the situated performance of deliberative routines is in big part shaped by contextual factors and particular endsin-view, possibly leading to new patterns and opening the possibility for reflection. The depiction of the process of situated performance and development of deliberative routines that we have described could therefore serve as an analytical tool to further explore deliberation in different street-level contexts. Specifically, we believe further research is needed that examines how to structure and manage street-level deliberation specifically when there is a relatively large amount of discretionary room . Relatedly, future research should scrutinize the interactions between street-level practitioners, managers, and policymakers and thoroughly analyze managerial attempts to facilitate change at the street level . Additionally, a more systematic understanding of practitioners' reflections could be developed and how that spurs both street-level decision-making and the development of deliberative routines . Finally, research is needed to understand the emotional work that street-level practitioners enact in order to maintain their internal deliberative processes to provide customized services . We conclude with the hope that, by offering an empirically grounded process depiction of situated performance and development of deliberative routines and by raising awareness of its consequences and risks, this study provides a basis to further explore these issues for both research and practice. --- Data Availability Because of the sensitive nature of the work observed, confidentiality promised to research participants, and the very limited possibility to anonymize our ethnographic data, data cannot be shared beyond what appears in the manuscript and its appendices. The online appendices include notes on positionality, an overview of research participants, interview guides, an overview of the analytical process, data coding examples, and a detailed case description. --- Supplementary Material Supplementary data are available at the Journal of Public Administration Research and Theory online. --- Conflict of Interest The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Deliberation is ubiquitous in street-level work. Scholars and practitioners increasingly promote it, as it has the potential to improve existing practices and procedures and provide customized, yet consistent, services. Little is known, however, about the situated performance of deliberation in street-level work. Drawing on Routine Dynamics Theory and based on an ethnographic study of street-level decision-making in child and family services in the Netherlands (including document analysis, ~300 hours of observations, and interviews in two teams in one organization), we uncover the performance of deliberative routines and their development over time. Demonstrating how contextual factors and the prioritization of particular ends play a role in these routines, we contribute to a better understanding of the dynamic and reflective performance of street-level deliberation. In addition, providing a more nuanced view of routines and elaborating on some possibilities for enabling management thereof, we contribute to a better understanding of the complex and iterative organization of street-level work.