key: cord-252839-mg7gxi3f authors: zhao, xiaolin; lan, mengxue; li, huixiang; yang, juan title: perceived stress and sleep quality among the non-diseased general public in china during the 2019 coronavirus disease: a moderated mediation model date: 2020-05-21 journal: sleep med doi: 10.1016/j.sleep.2020.05.021 sha: doc_id: 252839 cord_uid: mg7gxi3f background: the 2019 coronavirus disease (covid-19) has spread worldwide, and its associated stressors have resulted in decreased sleep quality among front-line workers. however, in china, the general public displayed more psychological problems than the front-line workers during the pandemic. therefore, we investigated the influence of perceived stress on the sleep quality of the non-diseased general public and developed a moderated mediation model to explain said relationship. methods: questionnaire-based surveys were conducted online from february 18–25, 2020 with 1,630 chinese participants (aged 18–68 years). results: around one-third (36.38%) of participants were poor sleepers during the covid-19 pandemic. moreover, higher perceived stress was significantly associated with higher anxiety levels, which, in turn, was associated with lower sleep quality. self-esteem moderated the indirect effect of perceived stress on sleep quality through its moderation of the effect of perceived stress on anxiety. this indicated that the mediation effect of anxiety was stronger in those with low levels of self-esteem than in those with high levels of self-esteem. conclusions: these findings suggest that both the sleep quality and perceived stress levels of the non-diseased general public required attention during the covid-19 pandemic. our findings also identify personality characteristics related to better sleep quality, demonstrating the important role of self-esteem in environmental adaptation. since december 2019, the outbreak of the novel coronavirus disease (covid-19) has 2 infected more than 80,000 individuals in china, and it has since been declared a global 3 pandemic [1] . according to the world health organization's report, by april 30, 2020, 4 this study was approved by the review board of the faculty of psychology of southwest 12 university (no. irb20200218). anonymous questionnaires were conducted via an online 13 survey platform-"surveystar"-from february 18-25, 2020 february 12: the government intensifies checks for confirmed cases, adopts a "reception new patients as much as possible" policy. february 28: the who raised the global risk level for an outbreak to "very high". march 10: all the 14 mobile cabin hospitals in wuhan were closed. to test the significance of indirect effects [52] . the 95% cis did not include zero, indicating a 1 significant effect. from february 4 to march 10, 2020; existing confirmed cases = cumulative confirmed cases -12 cured cases -death cases. the distribution of psqi scores is presented in figure 3 . we also calculated the mean scores 2 of the seven subscales: subjective sleep quality (mean = 0.94, sd = 0.76), sleep latency 3 (mean = 1.24, sd = 0.96), sleep duration (mean = 0.13, sd = 0.44), habitual sleep efficiency 4 (mean = 0.53, sd = 0.83), sleep disturbances (mean = 0.99, sd = 0.53), use of sleep 5 medication (mean = 0.04, sd = 0.31), and daytime dysfunction (mean = 1.02, sd = 0.96). 6 among the 1,630 participants, there were 1,037 (63.62%) good sleepers and 593 (36.38%) 7 poor sleepers. the results of pearson's correlations are presented in table 1 . as expected, higher perceived 13 stress was correlated with lower sleep quality. higher anxiety was related to higher perceived 14 stress and lower sleep quality. moreover, higher self-esteem was associated with lower 15 anxiety and better sleep quality. 1 perceived stress scale; sas = self-rating anxiety scale; rse = rosenberg self-esteem 3 scale; *** p < .001. 4 controlling for age, education, working or not (ie, whether they left the house to work), and 6 attention to covid-19, the mediation effect of anxiety was examined. results showed that a 7 higher level of perceived stress significantly predicted lower sleep quality (see model 1 of 8 table 2 ). higher perceived stress was also a predictor of higher anxiety (see model 2 of table 9 2). when controlling for perceived stress, higher anxiety significantly predicted lower sleep 10 quality (see model 3 of table 2 ). moreover, bootstrapping indicated that the mediation effect 11 of anxiety was significant (ab = 0.13, boot se = 0.01, boot 95% ci = [0.11, 0.15]), and it 12 accounted for 66.29% of the total effect. taken together, anxiety mediated the relationship 13 between perceived stress and sleep quality. 14 = self-rating anxiety scale; *** p < .001; ** p < .01. 2 controlling for age, education, working or not, and attention to covid-19, we conducted the 4 moderated mediation analysis. as table 3 shows, the interaction (model 1) between 5 perceived stress and self-esteem significantly predicted anxiety, suggesting that self-esteem 6 moderated the effect of perceived stress on anxiety. simple slope tests suggested that, for 7 individuals with high (mean + sd; b simple = 0.59, t = 13.06, p < .001) and low (mean -sd; 8 b simple = 0.73, t = 16.80, p < .001) self-esteem, higher perceived stress predicted higher 9 anxiety ( figure 4a ). nevertheless, the slope for individuals with low self-esteem was larger 10 than that for individuals with high self-esteem. further, self-esteem significantly moderated 1 the effect of perceived stress on sleep through anxiety. there was a significant indirect effect 2 at each level of self-esteem (table 4) ; however, the indirect effect of perceived stress on sleep 3 quality through anxiety was stronger at low levels of self-esteem. 4 table 3 also shows the interaction (model 2) between perceived stress and self-esteem, 5 which significantly predicted sleep quality. this suggests that self-esteem moderated the 6 direct effect of perceived stress on sleep quality. simple slope tests ( figure 4b) showed that, 7 for individuals with low self-esteem, higher perceived stress predicted lower sleep quality 8 (b simple = 0.76, t = 4.53, p < .001); however, for individuals with high self-esteem, perceived 9 stress was not related to sleep quality (b simple = 0.03, t = 1.56, p = .12). 10 note. n = 1,630. psqi = pittsburgh sleep quality index; pss = perceived stress scale; sas 1 = self-rating anxiety scale; rse = rosenberg self-esteem scale; *** p < .001; ** p < .01. 2 anxiety was stronger at low levels of self-esteem than at high levels of self-esteem. the direct 13 effect of perceived stress on sleep quality was moderated by self-esteem. 14 the number of poor sleepers in the current study was much higher than the proportion 15 reported in previous chinese studies, which were not related to better than that of the front-line medical staff (mean psqi = 8.58; [2]). we cautiously 10 speculate that the countermeasures for covid-19 may reduce the impact of the pandemic on 11 the sleep quality of the general public. on one hand, to cut-off the transmission of the virus, 12 the general public was encouraged to practice home-isolation and wear masks, which 13 effectively reduced the risk of infection. on the other hand, during the period of 14 home-isolation, the state has implemented many measures to ensure that the daily lives of the 15 general public are as normal as possible; for example, college students can take classes online 16 at home. 17 we found that higher levels of perceived stress predicted lower sleep quality, which is 18 consistent with previous studies [8] [9] [10] [11] [12] [13] . moreover, perceived stress affected sleep quality 19 through anxiety, indicating that perceived stress increased feelings of anxiety, which, in turn, 20 decreased sleep quality. these results were consistent with stress and coping theory, which 21 proposes that stress occurs when individuals perceive that the demands of environmental 1 stimuli exceed or tax their resources, which results in a changed emotional state (eg, anxiety) 2 that, in turn, affects one's health [56-59,18]. since perceived stress was measured by the 3 degree of unpredictability, uncontrollability, and overload [42] . in the current study, 4 participants with higher stress perceived lower control over their lives. accumulating 5 evidence has demonstrated that lower perceived control is associated with higher anxiety 6 levels and more anxiety symptoms [60-64]; therefore, our results were consistent with these 7 models of anxiety, which suggests that control over life plays an important role in anxiety 8 development [65] . in addition, we found that higher anxiety levels predicted worse sleep 9 quality. in line with this study, previous studies have consistently found that higher anxiety 10 levels were associated with worse self-reported health, decreased well-being, higher levels of 11 depression, increased disability, and cognitive impairment [66-72]. 12 our results showed that self-esteem moderated the relationship between perceived stress 13 and anxiety, which, in turn, moderated the indirect effect of perceived stress on sleep quality 14 through anxiety. specifically, the effect of perceived stress on anxiety was stronger in those 15 with low self-esteem vs. high self-esteem. these findings are consistent with tmt theory, 16 which suggests that high self-esteem helps buffer against anxiety [35, 36] . accordingly, faced 17 with the stressors induced by covid-19, participants with low self-esteem were more likely 18 to experience anxiety than were participants with high self-esteem. individuals with high 19 self-esteem typically hold more positive beliefs (eg, intelligent, popular, attractive, etc.) about 20 themselves relative to those with low self-esteem [73] [74] [75] . similarly, compared with 21 individuals with low self-esteem, those with high self-esteem are more confident in their 1 ability and more optimistic about their performance on future tasks, even following a failure 2 [76]. further, participants with high self-esteem display more self-protection and attribute 3 failure more to external factors than participants with low self-esteem [74,77]. these 4 characteristics of high self-esteem may help reduce anxieties related to threats. in addition, 5 we also found that self-esteem moderated the relationship between perceived stress and sleep 6 quality, indicating that higher perceived stress predicted lower sleep quality in those with low 7 self-esteem, but not in those with high self-esteem. these findings are consistent with 8 previous studies, suggesting that self-esteem is a protective factor for sleep [39, 41] . the roles of personal, relational, and collective self-esteem. plos one, 12 (8) 54. ning, c., lin, h., chen, x., qiao, x., xu, x., xu, x., shen, w., liu, x., he, n., & 42 a novel coronavirus 7 outbreak of global health concern the effects of social 9 support on sleep quality of medical staff treating patients with coronavirus disease 10 2019 (covid-19) in january and february 2020 in china long-term effects of extreme situational 13 stress on sleep and dreaming sleep 15 disturbance and its relationship to psychiatric morbidity after hurricane andrew long-term impact of 18 earthquakes on sleep quality predicting sleep quality from stress and prior sleep-a study of day-to-day 21 covariation across six weeks cross-sectional comparison of various sleep disturbances among sex-1 and age-matched hiv-infected versus hiv-uninfected individuals in china abnormal 5 night sleep duration and poor sleep quality are independently and combinedly 6 associated with elevated depressive symptoms in chinese rural adults more than a feeling: a unified view of stress 10 measurement for population science dynamics of a stressful encounter: cognitive appraisal, coping, and encounter 14 outcomes stress, appraisal, and coping the structure of 21 perceived emotional control: psychometric properties of a revised anxiety control 22 questionnaire conditioning and ethological models of anxiety 24 disorders: stress-in-dynamic-context anxiety models measurement of 27 perceived control over anxiety-related events exploring perceived control, a 29 low-control task, and a brief acceptance intervention in a low and high transdiagnostic 30 anxiety sample assessing the perceived predictability of anxiety-related events: a report on the 34 perceived predictability index anxiety and its disorders: the nature and treatment of anxiety 36 and panic consequences of anxiety in older persons: 39 its effect on disability, well-being and use of health services self-perception of physical health conditions and its association with 1 depression and anxiety among bangladeshi university students measurement and prediction of aging anxiety anxiety and its correlates among older adults accessing aging services vulnerability to stress, anxiety, and development of dementia in old age wolitzky-334. ournal of geriatric psychiatry, 19eider vulnerability to sorders in older adults: a comprehensive review anxiety about aging, resilience and 14 health status among chinese older adults: findings from honolulu and wuhan does high 17 self-esteem cause better performance, interpersonal success, happiness, or 18 healthier lifestyles? the costly pursuit of self-esteem self-esteem and self-serving biases in reactions to 22 positive and negative events: an integrative review self-esteem effects of self-esteem and performance 24 feedback on future affective preferences and cognitive expectations effects of self-esteem, perceived performance, and choice on causal 27 attributions sleep eeg, depression and gender gender differences in sleep disorders. current 31 opinion in pulmonary medicine psychosocial 33 factors and sleep efficiency: discrepancies between subjective and objective 34 evaluations of sleep the 36 relationship between subjective sleep estimation and objective sleep variables in 37 depressed patients discrepancy between subjective and objective sleep in patients with depression a pilot examination of self-esteem depression, and sleep in college women conceptualization, methodology, formal analysis, investigation, writing-original draft preparation, writing -review & editing. mengxue lan: conceptualization, investigation, formal analysis. huixiang li: investigation, formal analysis. juan yang: conceptualization, writing -review & editing, supervision, funding acquisition key: cord-277454-i8f7gckb authors: rauso, raffaele; nicoletti, giovanni francesco; zerbinati, nicola; lo giudice, giorgio; fragola, romolo; tartaro, gianpaolo title: complications following self-administration of hyaluronic acid fillers: literature review date: 2020-10-14 journal: clin cosmet investig dermatol doi: 10.2147/ccid.s276959 sha: doc_id: 277454 cord_uid: i8f7gckb the purpose of the present study is to review published literature regarding complications following self-administration of hyaluronic acid (ha) filler. the following keywords were searched in pubmed and cochrane database: filler and self injection, hyaluronic acid and self injection; filler and self administration; hyaluronic acid and self administration. two authors performed title and abstract eligibility assessment independently. gray literature and all articles cited in the included papers were also screened and their reference lists were examined to identify other potentially pertinent studies. non-english papers were excluded. a total of 4 complications following self injection of ha were identified. conversely, after performing a general search through the google internet search engine, with the item “self-injection of hyaluronic acid filler”, there were 604,000 hits. the number of articles reporting complications after the self administration of ha is few. despite that internet searches on the same topic shows that self-administration of ha fillers is a widely discussed phenomenon in several on-line forums. the present review suggests that complications after self-injection of ha are an under-reported phenomenon. the demand for non-invasive facial aesthetic procedures has increased dramatically in recent years. in 2018, more than 1 billion dollars were spent on injectable treatments by consumers. 1 injection of hyaluronic acid (ha) was the second most popular nonsurgical cosmetic procedure (after botulinum toxin injection) with over 800,000 treatments performed, an increase of almost 12% from 2017 to 2018 and a 60% increase from 2014 to 2018. 1 it is thought that the increasing social pressure placed on the younger generation via social media has been driving the overwhelming demand for cosmetic procedures. moreover, video platforms have helped to spread practical knowledge on the execution of such procedures. although most of these videos are supposedly addressed to practitioners, the free and easy availability allow people to watch, compare and reenact them. social media and the internet are not the only devices that have caused the normalisation of cosmetic procedures. platforms for the treatment to be marketed are provided. 2 technology has opened the doors to easy accessible and unregulated forums were self-injectable fillers can be bought easily. alarmingly, the general public's awareness to the risks of dermal fillers injections appears to be lacking. the purpose of the present review is to attest the incidence of reported complication after self-injection of ha filler. in order to attest the incidence of complications after selfadministration of ha fillers, the research was carried out on electronic databases, pubmed and cochrane databases identifying articles from january 2000 to july 2020. the search was conducted up to july 17th, 2020. articles language was limited to english using databases supplied filters. the following keywords were searched: filler and self injection, hyaluronic acid and self injection; filler and self administration; hyaluronic acid and self administration. two authors performed title and abstract eligibility assessment independently. disagreements between authors were resolved by consensus. when consensus was not reached, a senior member mediated. gray literature and all articles cited in the included papers were also screened and their reference lists were examined to identify other potentially pertinent studies. non-english papers were excluded. the online search yielded 712 records from pubmed database and 169 from cochrane library database (tables 1 and 2 ). as inclusion criteria were considered all the papers reporting complications following self administration of ha filler; all kinds of studies were considered, including case reports. non-english papers were considered as exclusion criteria. after screening the articles by titles and abstracts: a total of 10 articles were considered relevant and selected for full-text reading. scanning of gray literature and citations of included studies yielded no further relevant result. among the 10 papers considered for the present review, 6 did not meet the inclusion criteria and were consequently excluded. the remaining 4 articles underwent critical evaluation and selected for data collection. all selected papers were case reports. a total of 4 complications following self injection of ha were identified. when performing a general search through the google internet search engine, with the item "self-injection of hyaluronic acid filler", 604,000 hits comes out; furthermore, looking for the most frequent related questions posed, results shows: "can i inject hyaluronic acid myself?", "can you inject yourself with fillers?". an interesting point is that the answer to the first question, extracted from the most relevant site for that query, is self-injecting is not forbidden, but we must kindly warn you that it may lead to disappointing results. if you want to treat yourself with hyaluronic acid, make sure that a subcorrection always looks better than an overcorrection; for the second question the answer is please don't try to inject yourself with facial fillers -it is extremely dangerous! [. . .] without knowing the anatomy of face muscles, nerves and blood vessels you could cause irreversible facial paralysis, blindness and tissue necrosis. self-injection of ha filler is a widely discussed phenomenon in several on-line forums both in the italian and english language. specific sections can be found regarding do-it-yourself (diy) skincare and cosmetics procedures, with hundreds of patients sharing their own experiences on ha filler self-injection, including video tutorials and advice regarding the procedures and how to buy it online. the posts span from 2009 to the present day, leading us to think that self-injecting of ha filler is a widely used procedure. [3] [4] [5] [6] conversely, the present literature review showed a significant low incidence of reported complications following self-administration of ha filler: only 4 case reports have been published. [7] [8] [9] [10] three of these case reports referred to facial injection and one to penis injection; in all the cases ha filler was bought on the internet. regarding self-administration of facial filler, one paper presented the clinical case of a woman who was referred to the hospital with a 4-week history of suspicious upper lip swelling. a conservative approach was proposed to the patient and self-reduction of the clinical condition was observed within 2 months. 10 another paper presented a patient suffering from swelling around the nasolabial fold, which she had since her self-injection filler 10 months previous. the case was treated with hyaluronidase injection. 7 one more paper presented a patient with erythema and lumpiness around self-injection sites, also in this case resolved with hyaluronidase injection. 9 the last paper considered, described a penis injection with ha and the development of indurated, erythematous nodules on the entire penile shaft, glans penis and scrotum. only medical therapy, during a 3-day hospitalisation, was administered. 8 submit your manuscript | www.dovepress.com clinical, cosmetic and investigational dermatology 2020:13 the complications reported in the present review appear to be related to poor injection capability; however these complications can be also seen when injection is performed by a medical doctor who demonstrates poor practice in the injection of ha. high-risk complications did not arise in the present review. the comparison between the high numbers of tutorials and forums regarding self-injecting of ha filler and the low number of articles present in the current literature, showing complications after self-injection, leads one to think that this is an underestimated phenomenon. the first case report of self-injected ha was published by ono and hyakusoku in 2010. 7 the authors also performed a sort of "mini review" of literature regarding this topic, underlining that several materials, such as olive oil, automobile transmission fluid, mineral oil, sweet almond oil, [11] [12] [13] [14] [15] have been described to be self-injected to improve facial appearance, but no cases were reported in literature regarding complications following self-injected ha prior to their paper. 7 moreover, most of the patients in previous selfinjection case reports of various substances, had a history of psychosexual problems and had engaged in frequent, repeated self-injections. ono and hyakusoku stated it is extremely unusual for an individual without any history of psychological illness to self-inject for rejuvenation purposes. 7 however, as shown by common internet searches, it looks as if a large number of patients are looking up how to self-inject. several individuals admit to self-injecting with no anaesthesia, and suggest cooling the product with a refrigerant to reduce pain during injection; some others suggest applying aesthetic cream or haemorrhoid ointment; moreover, others claim to repeatedly use the same needle, keeping the surplus material in refrigerator for a couple of months. according to these patients, they can inject the materials just as well as a physician, and at a reduced cost. they are fearful about government restrictions on purchasing these products. the us food & drugs administration strictly regulates dermal filler commercialisation: only approved fillers can be sold to licensed doctors in specific clinical settings and lists unapproved uses and general risks, underlining that "having filler injected should be considered a medical procedure, not a cosmetic treatment." 16 the european union medical device regulation (mdr (eu) 2017/745) repealed the existing directives indicating the general and essential requirements that a medical device should have homogeneity among european union countries. its implementation was postponed to may 2021 due to covid-19 outbreak. authorised notified bodies assess and certify medical devices. once the certification is given, in order to be commercialised in italy, such devices are registered in a ministry of health data bank with technical and administrative information of each device. resorbable dermal fillers are classified as class iii risk since they suit the rule 7 statement "have a biological effect or are wholly or mainly absorbed [. . .]". although the notified body needs to thoroughly assess the design and production of the products based on efficacy and safety clinical data, there are currently no strict rules on selling and administration of such substances, since both resorbable and non-resorbable fillers are not classified as drugs but as medical devices. 17, 18 in 2018, brennan et al 19 performed an online study describing the use of diy botox and dermal filler motivations to self inject were mainly identified in improving appearance of lines and wrinkles and avoiding financial cost. sourcing routes were identified via discussion threads, ordering in bulk was common. injecting practice was mainly displayed through youtube tutorials. regarding the outcomes, several positive outcomes of diy procedures were posted to enhance this practice. last but not the least, the risk perception was high, associated with the fear of negative outcomes, although the high costs of professional treatments were a good motivation to engage in the risk. the paper published by brennan et al 19 shows exactly how widely diffused the self-injecting phenomenon is, so the question is "why in medical literature are such small numbers of paper presenting complications following selfinjecting filler present?" a clear explanation regarding the aforementioned question does not exist, however we could hypothesise that individuals looking for self-injecting filler avoid injecting deeply into facial layers and probably this could let to have only minor complications such as ecchymosis, lumpiness or overfilling. moreover, it is possible that in case of complications, individuals feel ashamed to refer to a physician to resolve the problem, furthermore because it is well known by patients that ha naturally resorbs within a number of months. the concern in medical literature arose almost 10 years ago, with the editorial published by pickett in 2011: "serious issues relating to counterfeit dermal fillers available from internet sources", nonetheless, the number of reported complications following self-injection of ha filler is low. 20 the self-injecting phenomenon is also advocated by the online availability of filler, especially the ones containing ha. the ministry of the health and regulatory orders should take care about online selling of these medical devices and avoid a wide distribution among nonprofessional users. in the present paper a review of complications following self-administration of ha fillers was performed; the number of reported complications is low although internet searches regarding the same topic show that selfadministration of ha fillers is a widely a discussed phenomenon in several on-line forums. the low number of reported complications could be related to 2 main points: the subject first wanted to avoid a medical consultation (to save costs), and secondly felt ashamed to go to a physician after it went wrong. another interesting point arisen in the present review is the wide availability on line of ha filler. ministry of health and regulatory should restrict orders only to medical doctors in order to stem the underreported selfinjection phenomenon. regulation of cosmetic interventions: research among the general public and practitioners available from: www.essentialdayspa.com/forum/viewforum.php?f= 6 complications after self-injection of hyaluronic acid and phosphatidylcholine for aesthetic purposes desire for penile girth enhancement and the effects of the self-injection of hyaluronic acid gel self-injection of dermal filler: an underdiagnosed entity? complications of self-injected facial fillers: a treatment conundrum in the uk. case rep surg self-injection with olive oil: a cause of lipoid pneumonia sclerosing lipogranulomatosis: a case report of scrotal injection of automobile transmission fluid and literature review of subcutaneous injection of oils penile paraffinoma: self-injection with mineral oil fat embolism after intrapenile injection of sweet almond oil subcutaneous oleomas induced by self-injection of sesame seed oil for muscle augmentation gua=italiano&id=4422&area=dispositivi-medici&menu=vigilanza#: ~:text=i%20%e2%80%9cfillers%e2%80%9d%20%2d%20sono% 20dispositivi,un%20dispositivo%20medico%20deve%20possedere. accessed saving face": an online study of the injecting use of diy botox and dermal filler kits serious issues relating to counterfeit dermal fillers available from internet sources the authors received no financial support for the research, authorship, and publication of this article. the authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. clinical, cosmetic and investigational dermatology is an international, peer-reviewed, open access, online journal that focuses on the latest clinical and experimental research in all aspects of skin disease and cosmetic interventions. this journal is indexed on cas.the manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. visit http://www.dovepress.com/testimonials.php to read real quotes from published authors. key: cord-025278-6ttdtjvn authors: rao, pritika title: behavioral economics in the time of coronavirus: rebellion or “willful ignorance” in the face of “grand challenges” date: 2020-05-27 journal: rev evol polit econ doi: 10.1007/s43253-020-00015-2 sha: doc_id: 25278 cord_uid: 6ttdtjvn this article considers the curious case of human behavior in the context of the coronavirus pandemic. we have observed that individuals, societies, and nations are exhibiting various irrationalities that are worth studying more closely. applying the insights and research of reputed behavioral economists to these unprecedented circumstances, we explore possible explanations for individual and collective actions that appear, in many cases, to be highly counterintuitive. in the face of large-scale global issues, that lazaric (2020) refers to as “grand challenges,” fraught with uncertainties and informational asymmetries, we delve deeper into the complexities of the factors that influence decision-making at various levels as we try to make sense of behavior. we wonder if reasons include the outright rejection of facts or perhaps the unwillingness to even receive information that has the potential adversely affect one’s welfare or self-interests—a tendency that grossman and van der weele (2017) term “willful ignorance.” we conclude with a few lessons and recommendations that can help understand and motivate behavior. why is it that the very same people who longed for days when they could be paid to do nothing but netflix the day away do not seem to want to do so? why is it that it is so much harder to convince individuals to comply with rules that are intended to protect them? why are we determined to see things the way we want to, despite very grim facts and statistics staring us in the face? in light of the coronavirus, we consider the behavior of individuals and arrive at some interesting conclusions. there is the obvious discounting, a term economists and psychologists are very familiar with-the tendency to trade off present benefits for future ones. it seems that for some, the present value of exercising the freedom to walk free in the streets, visit a local supermarket or attend a party is much higher than the future benefit of protection from a contagious disease. some persons discount future payoffs because the uncertainty of a future is much higher, particularly those who are naïve, or those who are much older and have lived through other epidemics such as the swine flu, ebola, hiv, and sars, and therefore see no reason for this virus to disrupt their lives. others may even believe that contracting the disease is inevitable and in fact better for herd immunity (a stance initially adopted by the uk government), creating little incentive for them to stay indoors and isolate. there are also those who believe very strongly in conspiracy theories. there are numerous articles, messages, and videos that have been circulating that endorse these diverse opinions, generating informational inconsistencies. but behavioral economics suggests that access to the right information may not be the only factor that influences socially responsible behavior. grossman and van der weele (2017) cite an important behavioral trait that they term "willful ignorance," or the act of "avoiding information about adverse welfare consequences of self-interested decisions"(p.1). their study focuses on self-image and indulgent behavior even at the cost of social harm. most often cited in research pertaining to climate change; this attribute also explains why many believe that environmental harm is not man-made, and in fact barely even real. what's more, people are reluctant to receive information on the topic (stoll-kleemann et al. 2001; norgaard 2006) , even if it is free to do so. numerous researchers, economists, and psychologists have found that this ignorance acts as a safeguard against the person's reputation, protecting their self-image (e.g., dana et al. 2007; benabou and tirole 2006; bem 1972; baumeister 1998; fiske 2013) . norgaard (2006) has stated in her research that this "fear of being a bad person" is a motivation for individuals to avoid learning and engaging with the facts on climate change. this may explain the behavior of persons who are wandering outdoors despite recommendations, guidelines, and laws that prohibit this type of activity in such dangerous times. this is not a criticism of those workers who are risking their lives to perform essential services or blue-collar workers who have no choice but to report to work during this time. this piece concerns those who (counter-intuitively) gather in groups in the midst of a nationwide lockdown (to clap loudly and clang pans to thank health workers), or those who confidently venture out of their homes, citing cynicism, misplaced optimism, and displaying outright rebellion. those who are bombarded with information at workspaces, on social media and in peer groups, cannot claim "ignorance," and are therefore more likely to practice social distancing and self-isolation since they do not want the negative perception it may attract. social proof theory also suggests that individuals are hugely influenced by their perception of what others around them are doing. those who are retired or those who work in more laissez-faire settings have limited access to this level and volume of information (usually traditional media such as the television or newspapers) that they can comfortably claim to have never seen. this may also explain why in the past few months with the furor surrounding the passing of the contentious https://en.wikipedia.org/wiki/citizenship_(amendment)_act,_2019 that sought to amend the definition of an illegal immigrant, and grant fast-track citizenship to minority groups who have fled from persecution in muslim-majority nations. coupled with the implementation of the https://en.wikipedia.org/wiki/national_register_of_citizens, young members of intergenerational families found it extremely hard to debate with older generations and express their views on their perceived discrimination and the resultant communal violence and angst that this sparked across the nation. of course, there is also a whole lot of confirmation bias in there but there is also what dan galai and orly sade call the ostrich effect (2006), which they define as the tendency to "avoid apparently risky financial situations by pretending they do not exist" (pp. 2743, 2744) . in situations like the present, when the risk of community transmission is high, seeing people congregate in groups right in the middle of a government imposed janata curfew (enforced across india in an effort to encourage social distancing and prevent exactly this type of behavior) is absolutely illogical. while this seems a lot like a blatant rejection of facts and an act of rebellion, it might actually point to something much deeper. individuals do not act in isolation-they consider the context of their larger environment and assess their response in light of external circumstances. lazaric (2020), in a chapter titled "cognition and routines dynamics in times of grand challenges," argues that agency is the real game-changer in the face of global problems such as climate change or widespread technological or societal transformation that she refers to "grand challenges." agency is key to the tackling of big problems and driving new patterns or courses of action that influence routines. she references the work of margaret archer who highlights the notion of "self-talk" or internal dialogue that individuals engage in while designing actions, thereby suggesting differences in mental operation across individual personality types (2003). archer defines these groups of agents-"communicative reflexive" or those who are distrustful of their internal dialogue and are mostly socially immobile, "autonomous reflexives" who rely on judgment and past contextual experience: "meta reflexive" similar to the previous group but with strong ideals that govern their thinking, making them critical of structures, constraints, and situations that are inconsistent with these lofty visions. a consideration of individual thought processes certainly influence behavior in the event of "grand challenges." these "ill-structured problems" are difficult to reconcile since there are numerous unknowns with undefined goals, multiple solutions, and paths or none at all without consensual agreement on the appropriate solution (jonassen 1997) . in the absence of well-defined general rules, heuristics and the uncertainty, learners devise solutions based on personal opinions or beliefs by evaluating, dismantling, and rebuilding existing practices. these existing patterns in an organization and by extension, society is sometimes so widespread that creating new routines and patterns become much harder. amid these constraints, the interactions between different learners help frame new solutions and practices for the collective. as lazaric (2020) states, "archer's work on diverse types of self-talk at the individual level may help to rethink the ostensive and performative co-constitution of routines." the anchoring principle also seems to explain why the current pandemic is not being taken as seriously as it should. the first piece of information that emerged was a rather optimistic half-truth "coronavirus is nothing more than a really bad flu" or some version of this statement. as a result, most reject anything that suggests that it is more severe than that-dismissing it as panic, paranoia, or speculation. deliberate action during the early onset of the spread of the virus in the form of stern factual statements by experts and governments would have been extremely beneficial. although it is much easier to sit at home and avoid a painful commute, research shows that people rarely like to disturb the status quo. banks and other marketing agencies have cleverly factored this into their communication in the form of default options, knowing that our innate humanness will cause us to fall back into familiar patterns, no matter how detrimental they may be to us and those around us (think, addictive behaviors). "fast thinking" as opposed to kahneman's slow thinking, relies on automatic processing and mental shortcuts while in this situation, a more deliberate, analytical thinking is required. what can actually get people to stay at home and practice self-isolation and/or social distancing? in retrospect, what would have helped immensely was rapid response. if officials were quick to recognize the scale of disruption this could cause (learning from china's attempt to tackle the matter privately internally leading to an unchecked proliferation of cases), and communicated the severity top-level down, the anchoring principle would have kicked into effect, and a cascading of errors could have been prevented at the group/society level. challenging currently held beliefs within intergenerational families by presenting facts through videos for instance may work, albeit only to a limited degree. disseminating responsibilities at a local level, on the other hand, tends to work very well. giving residential layouts, apartments, office complexes, districts, etc., the ability to enforce stringent measures has worked because it places individual behavior under the lens of someone in authority, where an individual's need to protect self-image will come into play. simple, direct communication such as the rate of transmission (1 person can infect 2-3 persons who in turn can go on to infect 2-3 persons each) is highly effective since it puts the focus on individual action and counters misplaced overconfidence. achieving a fine balance between providing just enough information and enforcing the law to prevent social interaction, while simultaneously exercising precaution and care not to induce panic is a delicate, yet important consideration in the present time. grossman and van der weele (2017) make an important distinction in terms of a signaling model where preferences are studied against material payoffs with either an intrinsic concern for social welfare or a preference for a self-image as pro-social actor. these preference-signaling models suggest two interpretations: 1. a social-signaling interpretation with an external observer. 2. a self-signaling interpretation with an internal observer (this is a dual self-signaling model introduced by prelec and bodner (2003) , and widely adopted thereafter, wherein the decision-maker and observer are two aspects of a divided self, where for instance, the decision-maker is an informed actor who is aware of preferences and the observer may be a future self who lacks introspective knowledge or awareness of past motivations (grossman and van der weele 2017). as explained above, groups of persons with access to information tend to largely fall in either one of the categories above-where they are subject to either an external observer's judgment (through the wider network of social media or highly engaged peer groups) or at the very least have a highly elevated social self that values collective welfare. in the absence of an external observer and with the observer in the self-signaling interpretation, we find ourselves in the baffling social situation that we are in now, with willfully ignorant persons "looking the other way" and creating an environment for collective social catastrophe. policy that focuses only on disseminating information may not be optimal. instead, enforcing accountability with an added emphasis on self-image can be used to benefit the common good. diminishing the possibility of ignorance (willful or otherwise) will require targeted measures in the form of outright questioning or challenging of beliefs or establishing an external agent that uses the self-image aspect of behavior to their advantage. as stated previously, decisions are not made in isolation. this is the subject of research of many behavioral economists who have stated that in every type of organization, there are relationships or behavior that lie between custom and tradition (formal or informal rules). routines are defined as patterns of behavior that are motivated by a set of rules that comprise of past capabilities, memories, information, knowledge, and habits (becker et al. 2005) . routines involve both cognitive and political dynamics that inform collective learning, just as habits also take knowledge, social, and institutional structure considerations into account (lazaric 2000) . routines are adopted by individuals, but in the context of larger society. lazaric and denis (2001) have found that changing existing practices may lead individuals to adopt a defensive posture that extends beyond their cognitive level. a political level of motivation arises that may lead to conflict, despite an obvious opportunity for better learning and elevated social status. people flocked to beaches around the world in recent weeks from the usa to australia, declaring rather proudly that corona wasn't going to stop them from going about their lives. it seems that years of societal conditioning whether in the form of mantras such as "this too shall pass," "business as usual," or "not giving in to fear" have created large institutional biases. a review in the lancet 1 reported numerous negative effects of the quarantine ranging from confusion and anger to post-traumatic stress. it appears that democracies such as america, italy, and india are struggling in particular (compared to say, china) because they are accustomed to a certain level of freedom and agency that is suddenly revoked in a crisis of this kind. situations of uncertainty and unpredictability, no doubt, affect organizations and their ability to learn. furthermore, groups, teams, or "communities of practice" play a vital role in the creation of knowledge (cohendet and llerena 2003; lazaric and raybaut 2004) . within these communities, the presence of heterogeneity in the form of multiple aims and goals among members can hinder the ability to quickly resolve issues (march and simon 1958) . contradictory messaging from world leaders have left people confused, causing them to revert to long-held beliefs. in the case of the virus, the uk adopted a relatively more ad hoc approach and severely delayed testing and provision of care, as boris johnson with his classic british "carry on" rhetoric, was reluctant to enforce stringent containment measures. simon (1991) believes that the existence of some members who possess loyalty or an open mind give rise to a selection mechanism that may help convergence towards the larger organization's goal. in the healthcare industry, the innovation for cancer care in africa 2 project has noted that a unified goal on healthcare is critical to ensuring better outcomes. policy recommendations that read like a wish list are rarely implemented effectively because they are too vague. within markets too, great variety and heterogeneity is not necessarily a success. despite an increased amount of products, diagnostic firms, information, and healthcare providers, numerous cases of cancer are still reported in countries such as india and africa, because there exist issues some of which are societal stigma, habits, and beliefs that hinder a patients' ability to access quality, timely care. it is evident from the literature that merely an overload of information does not motivate individual behavior, routine, or collective change in the event of a "grand challenge." there are important considerations to be made regarding individual decision-making, routines, and signaling issues that are largely ignored when countries and organizations attempt to motivate behavior. conflicts of interest the author declares that there is no conflict of interest. the impact of virtual simulation tools on problem-solving and new product development organization self-perception theory incentives and prosocial behavior routines and incentives: the role of communities in the firm exploiting moral wiggle room: experiments demonstrating an illusory preference for fairness the 'ostrich effect' and the relationship between the liquidity and the yields of financial assets self-image and willful ignorance in social decisions instructional design models for well-structured and iii-structured problem-solving learning outcomes the role of routines, rules and habits in collective learning: some epistemological and ontological considerations forthcoming) cognition and routines dynamics in times of grand challenges how and why routines change: some lessons from the articulation of knowledge with iso 9002 implementation in the food industry knowledge creation facing hierarchy: the dynamics of groups inside the firm people to protect themselves a little bit: emotions, denial, and social movement nonparticipation time and decision: economic and psychological perspectives on intertemporal choice theories of bounded rationality the psychology of denial concerning climate mitigation measures: evidence from swiss focus groups key: cord-264785-kkd2pyp3 authors: plevinsky, jill m; young, melissa a; carmody, julia k; durkin, lindsay k; gamwell, kaitlyn l; klages, kimberly l; ghosh, shweta; hommel, kevin a title: the impact of covid-19 on pediatric adherence and self-management date: 2020-09-26 journal: j pediatr psychol doi: 10.1093/jpepsy/jsaa079 sha: doc_id: 264785 cord_uid: kkd2pyp3 the covid-19 pandemic has presented unique circumstances that have the potential to both positively and negatively affect pediatric adherence and self-management in youth with chronic medical conditions. the following paper discusses how these circumstances (e.g., stay-at-home orders, school closures, changes in pediatric healthcare delivery) impact disease management at the individual, family, community, and healthcare system levels. we also discuss how barriers to pediatric adherence and self-management exacerbated by the pandemic may disproportionately affect underserved and vulnerable populations, potentially resulting in greater health disparities. given the potential for widespread challenges to pediatric disease management during the pandemic, ongoing monitoring and promotion of adherence and self-management is critical. technology offers several opportunities for this via telemedicine, electronic monitoring, and mobile apps. moreover, pediatric psychologists are uniquely equipped to develop and implement adherence-promotion efforts to support youth and their families in achieving and sustaining optimal disease management as the current public health situation continues to evolve. research efforts addressing the shortand long-term impact of the pandemic on pediatric adherence and self-management are needed to identify both risk and resilience factors affecting disease management and subsequent health outcomes during this unprecedented time. under typical circumstances, approximately 50% of children and 65-90% of adolescents are nonadherent to their treatment regimens (hommel et al., 2009; logan et al., 2003; rapoff, 2010) . nonadherence adversely impacts health outcomes and often leads to unnecessary treatment escalation (carmody et al., 2019) , as well as increased healthcare utilization (mcgrady & hommel, 2013) . given the prevalence and multi-faceted impact of nonadherence on pediatric health outcomes, the primary goal of this article is to identify and address how circumstances surrounding the covid-19 pandemic may affect adherence and self-management among youth with chronic medical conditions. this article will (a) provide an overview of the ways in which the covid-19 pandemic may exacerbate barriers to adherence and self-management; (b) address healthcare disparities including how covid-19 may result in greater consequences for adherence and self-management among underserved populations; and (c) offer suggestions for adapting and virtually delivering evidence-based interventions for monitoring and promoting pediatric adherence and self-management during covid-19. the pediatric self-management model (modi et al., 2012) conceptualizes pediatric disease management as not only medication-taking but also healthcare maintenance tasks (e.g., blood draws, routine procedures, appointment attendance), adjunct therapies (e.g., physical therapy), and health behaviors (e.g., exercise, nutrition, sleep). the model poses that both modifiable (i.e., psychological symptoms, treatment regimens) and nonmodifiable (i.e., cognitive function, socio-demographics) factors influence adherence to disease management tasks across the following four levels: individual, family, community, and healthcare system. while the long-term impact of covid-19 on health outcomes remains unknown, the immediate obstacles to self-management and treatment adherence are apparent and ever present across multiple systems, and each of these domains has been strained by the pandemic. therefore, it is important to identify and address potential factors specific to the covid-19 pandemic that may exacerbate poor adherence and self-management and highlight how pediatric psychologists can support these behaviors as the pandemic continues. aspects of physical health, psychological functioning, and cognitive processes that may ordinarily pose challenges for self-management and adherence among youth may be even more detrimental during the pandemic. a reduced focus on symptom monitoring and potential disruptions in routine medical care due to covid-19 may result in a false sense of physical health or treatment effectiveness, thus leading to a potential lapse in treatment adherence (hanghoj & boisen, 2014) . psychological and behavioral problems are also associated with greater interruptions in pediatric adherence and self-management (modi et al., 2012) . while many are adjusting well to the stay-athome orders, several experts indicate that there has been an increase in internalizing and externalizing symptoms in children and adolescents (fegert et al., 2020) . deficits in cognitive processes (e.g., executive functioning) as a result of increased difficulties with mood (robinson et al., 2015; snyder, 2013) likely interfere with treatment adherence (duke & harris, 2014; stern et al., 2018) . specifically, when youths' self-management responsibilities outweigh their cognitive capacity to successfully manage their treatment regimen, adherence and self-management behaviors suffer (sonney & insel, 2019) . additionally, increased variability in daily structure and routine during the pandemic may contribute to increased forgetting and decreased self-monitoring, both of which are very common barriers to adherence reported across almost all pediatric populations (hanghoj & boisen, 2014) . while youth and their families may have experienced some declines in functioning affecting adherence during this public health crisis, others may have noticed improvements in overall functioning that may support adherence and self-management. for one, the impact of daily stressors that may impact adherence such as missed school, participation in activities, and concerns about friends (compas et al., 2012) likely have lessened due to social distancing guidelines. additionally, at least one study among adults with asthma (e.g., kaye et al., 2020 ) observed a positive change in rates of adherence during the covid-19 pandemic, providing added support for improved adherence and self-management for a subgroup of individuals. the impact of variability in daily structure and routine during the pandemic extends to caregivers and the family system. potential changes within the family system, such as caregivers having to physically go into work or working from home while simultaneously providing childcare and/or filling the role of a classroom teacher, may place greater demands on youth to perform self-care tasks independently. in contrast, increased parental supervision and support in the home may benefit adherence and self-management. this may also be an opportune time to refine strategies to improve self-management in cases where parent support and supervision has increased. however, increased parental involvement may exacerbate difficulties in cases where parental over-involvement constrains the normative development of independent self-management, especially in adolescents and young adults who otherwise would be spending more time outside the home and taking more responsibility for their treatment regimen. additionally, many children and adolescents receive support and medical care at school or via routine visits with in-home medical personnel to support self-management and adherence, yet in many cases these supports were abruptly withdrawn due to school closings and other covid-19-specific precautions. during the covid-19 pandemic, a host of medical procedures and treatments deemed non-critical, including healthcare maintenance appointments (e.g., physicals, routine follow-ups) were canceled (center for disease control and prevention, 2020). consequently, youth who were previously receiving adjunct therapies (e.g., physical, occupational, or psychosocial therapies) experienced an abrupt stop and/ or prolonged interruption in services. under typical circumstances, such large gaps in treatment would be considered nonadherence. moreover, the rapid adjustment to telemedicine was especially complex for pediatric healthcare systems, requiring medical centers to quickly adapt to using new technologies to provide care (patel et al., 2020) . despite the gradual reopening of healthcare services, covid-19-related precautions (e.g., limited capacity for face-to-face appointments, additional time to sanitize equipment, extended wait times, postponing of appointments) continue to pose threats to effective adherence and self-management. these rapid deaccelerations in care delivery likely contributed to unprecedented levels of nonadherence caused by healthcare system factors. additionally, families with youth who are immunocompromised may now be fearful of returning to the hospital for fear of contracting covid-19 (headley, 2020) . overall, families' experiences with lapses in insurance coverage, the burden of the cost of these services, limited accessibility to in-home medical personnel, and worry about returning to routine in-person care during the pandemic are likely impacting pediatric disease management as well. self-management behaviors that promote health outcomes such as exercise, nutrition, sleep, social interaction, and reducing sedentary behavior (e.g., screen time) have likely also been altered by the pandemic. for example, many youth received the bulk of their physical activity, nutritious meals, and social interaction with peers at school (wechsler et al., 2000) , which was closed to reduce the spread of covid-19. stay-at-home orders are critical for reducing the spread of covid-19 and, on one hand, may create or exacerbate poor adherence and self-management; but they may also create opportunities for improved adherence and self-management. some families may be cooking at home more leading to positive changes in diet, and a more flexible schedule may allow for more time for daily physical activity, relaxation for stress management, and hours of sleep per night. notably, the detrimental impacts of the covid-19 pandemic that can exacerbate nonadherence are disproportionately higher in low-socioeconomic communities, compounding pre-existing health disparities. over one-third of vulnerable populations have reported job losses and material hardship, which may have ended insurance coverage for many youth (jenco, 2020; millett et al., 2020; van dorn et al., 2020) . telehealth has offered benefits to vulnerable populations (i.e., removing transportation barriers, not missing work due to a child's medical appointment). still, the pandemic created additional barriers to healthcare service delivery for underserved youth and their families, including barriers to telemedicine (e.g. inability to acquire appropriate technology, affordability of internet access), changes to medical appointment scheduling, difficulty accessing interpreter services, and visitor restrictions (e.g., only one caregiver being allowed to accompany the child) at the hospital. quickly having to learn and navigate new technology systems to access healthcare can result in frustration and reduced utilization of care for these families as well (children's health fund, 2020). additionally, adherence and self-management support via psychology, social work or child life services may be limited given reduced capacity of these services due to limited staff hours, reduction in hospital revenue resulting in temporary discontinuation of services, or time needed to transition to telehealth platforms. last, pediatric patients from underserved populations likely face reduced community supports (i.e., boys and girls club) and reduced access to supportive health services via their school system (e.g., physical education, school nurse support). given that the pandemic is differentially affecting underserved populations, they are more vulnerable and therefore at greater risk for poorer adherence and self-management as a result. it is incumbent on providers to proactively identify and address challenges to adherence and selfmanagement with communication at the forefront of this process. patient-caregiver-provider communication is critical to identifying adherence and selfmanagement concerns and enacting individual, family, community, and healthcare system-level interventions to identify and develop effective solutions to barriers. for example, prior to the pandemic, a multidisciplinary urban clinic serving youth with hiv developed a robust and effective adherence support program, which relied on frequent clinic appointments, strong patient-provider relationships, and directly observed therapy. in response to the pandemic, the clinic adapted this model and has been proactively contacting patients to assess medication needs, explain new clinic procedures, and provide relevant covid-19 education to patients and families via frequent phone check-ins, directly observed therapy via telemedicine, and connecting patients with medication delivery services (armbruster et al., 2020) . while resource and time intensive, this approach may serve to mitigate risk factors and minimize consequences of nonadherence during this time. for patients with chronic conditions, regular outpatient consultation and disease monitoring via telemedicine are critical to promoting continued adherence and self-management during the pandemic. while providers may have reservations about the effectiveness of telemedicine, pre-covid-19 studies directly comparing traditional face-to-face versus telemedicine services have not found telemedicine to be inferior (bahrani et al., 2017; tates et al., 2017) . virtual communication platforms such as messaging embedded in the electronic medical record and hipaa-compliant smartphone applications (e.g., doximity) can also enable communication sharing in the absence of face-toface visits. many of these platforms also enable patients to share pictures, videos, and other helpful data so that providers can deliver targeted recommendations and support. regardless of the platform, it is crucial for providers to recognize how various aspects of the pandemic may be contributing to poorer adherence and self-management as previously discussed. providers should maintain a non-judgmental stance in order to yield more accurate information while avoiding evasive or defensive reactions (rapoff, 2010) . many families are having to make compromises regarding how time and resources are spent, and it is critical that providers take the time to understand each family's circumstances in order to align and set the stage for collaborative problem-solving. increased assessment and monitoring are also recommended, as a variety of strategies exist to assess adherence, including assays, observation, electronic monitors, pill counts, provider estimates, and patient/ caregiver report (mcgrady et al., 2018) . while access to bioassays may be restricted in the covid-19 pandemic, others can be modified and implemented in the absence of face-to-face visits. video observation (i.e., either live or recorded and shared electronically) can offer insight into how well a treatment regimen is performed (e.g., exercises for physical therapy, inhaler use, chest wall oscillation, etc.). moreover, home observations can reveal contemporaneous variables related to treatment adherence that may be amenable to intervention (mash & terdal, 1988) . patient and parent reports including global reports, structured interviews and questionnaires, and daily diaries can be easily adapted to telemedicine with patients or parents recording specific adherence behaviors over time (plevinsky et al., 2020) . this format can be particularly useful for identifying problem areas and problem-solving with families around their daily routine in order to maximize adherence. daily monitoring can improve adherence (greaves et al., 2011) and facilitate caregiver monitoring and implementation of behavioral strategies to promote adherence (e.g., token economy). adherence apps are one form of intervention freely available to youth and families with access to a smart phone or tablet. these apps can provide scheduled reminders, allow users to track adherence behaviors over time, and allow users to share these reports with their providers (carmody et al., 2019) . app-based medication adherence interventions have been associated with short-term improvements in adherence (badawy et al., 2017) , therefore these solutions can serve to supplement behavioral health interventions via telemedicine, or bridge patients until more intensive adherence interventions (e.g., accessing a psychologist) are available. although the circumstances surrounding the covid-19 pandemic and its broad impact (both positive and negative) across individual, family, community, and healthcare systems factors impact pediatric adherence and self-management, pediatric psychologists have the expertise to recognize, assess, and address these challenges to promote health outcomes. future research ought to utilize a mixed-methods approach to examine how the covid-19 pandemic has affected pediatric adherence and self-management in order to best inform clinical care and healthcare policy development. research is especially needed to examine the extent to which the pandemic has exacerbated pre-existing pediatric healthcare disparities that affect these outcomes and health outcomes broadly. digital tools, such as electronic adherence monitors, adherence-promotion mobile apps, and telehealth can be used to facilitate these efforts (stiles-shields et al., 2020) . youth with chronic medical conditions and their families are resilient, and with support from their medical teams and behavioral health providers, can achieve optimal adherence and self-management despite the challenges brought about by the covid-19 pandemic. however, we must acknowledge the potential enduring adverse effects of the pandemic on pediatric adherence and self-management. long-standing adverse effects may come as a result of unemployment and associated loss of family healthcare benefits, as well as youth and caregiver mental health sequelae due to prolonged social isolation or other pandemicinduced stressors. families may also receive reduced support from illness-specific non-profit foundations due to financial strain. furthermore, youth with comorbid learning disabilities may receive reduced special education support from schools in developing skills necessary for optimal adherence and selfmanagement (e.g., problem-solving). as the current public health situation evolves, pediatric providers will need to continue to support these youth and their families in being able to adapt to uncertainties, establish new routines, access healthcare (e.g., medications, medical interventions, healthcare services), and use new technologies (e.g., telemedicine, adherence apps) to promote disease management and reduce poor health outcomes. addressing health inequities exacerbated by covid-19 among youth with hiv: expanding our toolkit medication adherence and technology-based interventions for adolescents with chronic health conditions: a few key considerations telephonic review for outpatients with epilepsy-a prospective randomized, parallel group study longitudinal non-adherence predicts treatment escalation in paediatric ulcerative colitis interim cdc guidance on handling non-covid-19 public health activities that require face-to-face interaction with clients in the clinic and field in the current covid-19 pandemic coping with chronic illness in childhood and adolescence executive function, adherence, and glycemic control in adolescents with type 1 diabetes: a literature review challenges and burden of the coronavirus 2019 (covid-19) pandemic for child and 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in pediatric chronic illness: a systematic review assessing differential impacts of covid-19 on black communities pediatric self-management: a framework for research, practice, and policy rapid development of telehealth capabilities within pediatric patient portal infrastructure for covid-19 care: barriers, solutions, results patient-reported outcomes for pediatric adherence and self-management: a systematic review adherence to pediatric medical regimens functional neuroimaging of working memory in survivors of childhood brain tumors and healthy children: associations with coping and psychosocial outcomes major depressive disorder is associated with broad impairments on neuropsychological measures of executive function: a meta-analysis and review exploring the intersection of executive function and medication adherence in school-age children with asthma a longitudinal study of depressive symptoms, neuropsychological functioning, and medical responsibility in youth with spina bifida: examining direct and mediating pathways considerations and future directions for conducting clinical research with pediatric populations during the covid-19 pandemic the effect of screen-to-screen versus face-to-face consultation on doctor-patient communication: an experimental study with simulated patients covid-19 exacerbating inequalities in the us using the school environment to promote physical activity and healthy eating we are grateful for support from the national institutes of health, including the national institute of child health and human development (t32 hd068223). conflicts of interest: none declared. key: cord-257003-749zpxuy authors: onchonga, david; omwoyo, joshua; nyamamba, duke title: assessing the prevalence of self-medication among healthcare workers before and during the 2019 sars-cov-2 (covid-19) pandemic in kenya date: 2020-08-14 journal: saudi pharmaceutical journal : spj : the official publication of the saudi pharmaceutical society doi: 10.1016/j.jsps.2020.08.003 sha: doc_id: 257003 cord_uid: 749zpxuy abstract background self-medication plays a key role in public health as it influences both negatively and positively on the health of individuals and the existing healthcare systems. this is especially the case during public health emergencies like the 2019 sars-cov-2 disease. objectives the study aimed at assessing the prevalence of self-medication before and during the outbreak of covid-19 pandemic and its associated factors. methods stratified sampling was used to select 379 study respondents. the authors developed an online questionnaire, pretested and submitted to various online professional groups of different cadres of health workers. collected data was analysed using descriptive and inferential statistics. the data was presented in tables, graphs, percentages, and cross-tabulation with different variables. multivariable logistic regression was used to ascertain factors that influence an individual’s desire to self-medicate and associations were considered significant at p<0.05. results the overall prevalence of self-medication increased from 36.2% (n=137) before the pandemic to 60.4% (n=229) during the pandemic. the respondents' gender, level of education, age, marital status, level of participation in physical activity, and drug reaction events, were significantly associated with self-medication before and during the outbreak (p < 0.05). multivariable logistic regression analyses showed that engaging in physical activity, working during the day and being healthy were less likely to choose self-medication (p < 0.01). conclusion self-medication is an important health issue, especially during the covid-19 pandemic. continuous awareness creation and sensitization could help in reducing self-medication practices among healthcare workers. self-medication also known as self-care and/or self-administration of medication is a common practice across the world (hughes et al., 2001) and it involves situations where individuals, families, and/or communities take medicines to treat health conditions or symptoms without prescription or diagnosis from a qualified healthcare professional (bennadi, 2014; guzmán et al., 2000; ruiz, 2010) . although self-medication has been practiced in many generations (huffman, 2001) , it is becoming a significant area of interest in healthcare research as it gives individuals with minor ailments freedom to make independent choices on how to manage their own health and wellbeing (hughes et al., 2001) . research has demonstrated that there are a number of merits attributed to self-medication, such as improved access to medicines, especially over-the-counter drugs, which eases the burden levied to skilled physicians and pharmacists in dealing with minor illnesses (powis and pj rogers, 1996) . studies have shown that although self-medication empowers individuals and communities to take control of their wellness, it has been associated with medical challenges (mandal, 2015) , which may have adverse impacts on their lives. this has been attributed to uninformed acts such as incorrect dosage, incorrect diagnosis of a particular health condition, and improper route of administration of the self-medicated drugs. in addition, they may be using medicines for longer than the recommended time by the manufacturers, with a possibility of developing risk of dependence leading to abuse, improper storage of drugs, inappropriate choice of drug therapy, and increased prevalence of pathogenic resistance to drugs are some of the adverse effects (menary et al., 2011) . consumption of drugs without a prescription is triggered by factors such as the availability of drugs, easy access to drugs without time limits, improved supply of different varieties of medicines at affordable prices, and convenience in access to drugs compared to seeking treatment in the healthcare facilities (smith, 1996) . a recently published google trends study on the interest in self-medication during covid-19 pandemic indicated an upward trend. the study indicated an increase in the number of searches for self-medication worldwide since the pandemic was declared, and this would be an indication of increased interests in self-medication (onchonga, 2020) . self-medication is commonly practised in countries where human resources for health are constrained. most self-medication practices are triggered by relatively long waiting time in the health facilities, difficulties in securing an appointment with physicians, frequent closures of health facilities, recurrent stock-outs of essential medicines, and delays in getting treatment during emergencies (parulekar et al., 2016) . for healthcare workers, research has revealed that the circumstances and the environment in which they work predisposes them to accessing drugs during their routine work. although majority of the healthcare workers may be knowledgeable about the dangers posed as a result of self-medication, most of them find solace in self-medication especially when faced with work-related pressure, discomfort and anxiety in their workstations (omolase et al., 2011; rotenberg, 2009 ). currently, the world is struggling with covid-19 pandemic (lai et al., 2020; weiss and leibowitz, 2011; zu et al., 2020) , which has been declared a global public health emergency (who, 2020) . due to its fast spread, the disease has threatened lives and caused psychological distress and anxiety to both frontier healthcare workers and the general public in many parts of the world (holmes, 2003) . this situation has complicated the already fragile healthcare systems in resource-limited settings, especially those offering maternal and child health services (onchonga et al., 2020a (onchonga et al., , 2020b . the focus has shifted to combating the pandemic; thereby curtailing the strides made in other healthcare indicators. the current situation has been exacerbated by inadequacies in healthcare infrastructure, essential medical equipment in health facilities and inadequate health workforce. as a result, the available workers are forced to work for long hours, sometimes under difficult circumstances (bogren et al., 2019) , which prompts them to self-medicate to relieve the discomfort and anxiety attributed to burnouts. this cross-sectional study was designed to investigate the pattern of self-medication among healthcare workers before and during the covid-19 pandemic. the objectives of the study included: (a) to evaluate the prevalence of self-medication reported by healthcare workers before and during the outbreak, (b) to identify the common conditions for self-medication before and during the outbreak (c) to investigate the sociodemographic characteristics and health patterns associated with self-medication among different cadres of healthcare workers before and during the outbreak. it was envisaged that the results will inform healthcare policymakers on measures to put in place so as to improve the well-being of healthcare workers as they strive to save lives. this was part of a larger study that was conducted in kenya on the effect of the covid-19 disease among healthcare workers. the study population consisted of 385 healthcare workers that were directly involved in the management and control of the covid-19 disease pandemic. the study employed stratified sampling. various cadres of healthcare professionals were used as strata. an online questionnaire was developed, pretested, revised, and sent to different healthcare professionals' online groups and platforms such as whatsapp, messenger, and facebook. from each stratum, data was collected through random sampling of the received questionnaires until the required sample was achieved. the shared questionnaire was made anonymous to ensure data confidentiality and reliability. a questionnaire was developed by the investigators, which contained respondents' sociodemographic characteristics such as age, marital status, gender, level of education, religion, and cadre. also, it contained questions on the prevalence of self-medication before and during the outbreak, conditions treated for self-medication before and during the outbreak, reasons for preferring self-medication before and during the outbreak, respondent's attitude regarding self-medication, and knowledge and perceptions regarding self-medication. adverse drug reaction experiences were also investigated. collected data was analysed using the statistical package programme for social science (spss) version 23.0.0.by ibm. data was analysed and summarized using descriptive and inferential statistics, and later presented in tables, graphs, percentage, and cross-tabulation. multivariable logistic regression analyses were used to ascertain factors that influence an individual's desire to self-medicate, and associations were considered significant at p<0.05. the approval to conduct this research was obtained from the jaramogi oginga odinga teaching and referral hospital ethical review committee (ierc/jootrh/209/20). all the respondents were well-versed on study intentions and were required to consent before admission to the study. out of a targeted sample of 385 respondents, approximately 98.4% (n=379) questionnaires were correctly filled and returned. a total of 14 cadres participated in the study where 30.6% (n=116) were nurses. regarding the gender of participants, 51.5% (n=195) were female and 91.3% (n=346) were christians. about 65.4 % (n=248) were married and 59.6% (n=226) had a university degree as shown in table 1 . ( table 1 to be placed here) in this study, 50.9% (n=193) reported having felt unwell in the last three weeks preceding the interview. approximately 60.4% (n= 229) reported having taken medicines without a doctor's prescription in the last 21 days preceding the study. this was a 24.3% increase since those who had self-medicated before the covid-19 outbreak were 36.1% (n=137). the respondents were also asked about the conditions that necessitated self-medication. approximately 42% (n=139) mentioned headache and migraine, 15% (n=51) indicated joint and muscle pains, and 13% (n=43) mentioned running nose (figure 1 ). there were no differences on the conditions that necessitated self-medication before and during the outbreak. ( figure 1 to be placed here) about 19.8% (n=75) of the respondents reported to be of perfect health, 74.7% (n=238) had good health, and 5.5% (n=21) had average or poor health status. approximately 90% (n=341) of the respondents did not have any known psychiatric conditions, while 77.6% (n=294) were actively participating in physical activity. sleeping patterns were also investigated. about 14.8% (n=56) of the respondents reported sleeping for more than eight hours a day, 79.9% (n=303) had a sleeping pattern of between five and eight hours a day, and 5.3% (n=20) had a sleeping pattern of below four hours a day. there were no differences in sleeping patterns before and during the outbreak. chi-square test was conducted to compare self-medication before and during the outbreak with sociodemographic variables. the results showed statistically significant differences between self-medication and gender, physical activity, adverse drug reaction, work shift, marital status, level of education, and cadre. there was no statistical significance between self-medication and residency of respondents, health status, psychiatric condition, place of work, and sleeping patterns. (table 2 .) ( table 2 to be placed here) the study applied multivariable logistic regression analyses to ascertain factors influencing an individual's desire to self-medicate. the respondents that undertook physical activity, worked on day shift and were healthy; were less likely to self-medicate (p < 0.01). variables such as gender, drug reaction, reading drug instructions before use, level of education, having a known psychiatric condition, and perceived health status did not correlate with self-medication. (table 3 ). ( table 3 to be placed here) the number of respondents who read the manufacturer's manual/leaflet all the time before purchasing medicines increased from 58.8 % (n=223) before the outbreak to 72% (n=273) while those who did not read at all reduced from 5.1 % (n=19) before the outbreak to 1% (n=4) during the outbreak. about 70.4% (n=267) of the respondents noted that self-medication was not safe. regarding the route of administration of the purchased medicine, dosage, and side effects, there was an increase in knowledge from 69.4% (n=263) before the outbreak to 75% (n=284) during the outbreak, an indication of an increase in knowledge regarding the route of administration of the purchased medicines. about 31.1% (n=118) considered the brand of the medicine, 18.5% (n=70), the pharmaceutical company manufacturing the medicine, while 17.4% (n=66) considered the cost. access to selfmedication changed significantly before and during the outbreak. about 16.9% (n= 64) obtained the medicines from the primary health facility, 56.5% (n=214) from pharmacy stores while 26.6% (n=101) from hospital pharmacies before the outbreak, while, 89.5% (n=340) obtained medication from pharmacy stores and only10.5% (n=39) from primary health facilities. none of the respondents obtained medication from hospital pharmacies during the outbreak. among the respondents who self-medicated, 22.4% (n=85) had experienced perceived adverse drug reaction during the outbreak. there was a significant association between self-medication and adverse drug reaction during the outbreak (x 2 = 4.479, p = 0.034). further, there was a significant association between taking drugs for chronic illness and experiencing adverse drug reactions during the outbreak (x 2 = 4.897, p = 0.02), with results suggesting that those taking drugs for chronic illness during the outbreak were more likely to develop adverse drug reactions. adverse drug effects prompted approximately 60.8%(n=62) to stop self-medication. ( table 4 ). the study did not find any significant association between self-medication and adverse drug reaction before the outbreak of covid-19. ( table 4 to be placed here) of the 379 respondents, 214 (64.3%) believed that the covid-19 pandemic had necessitated self-medication. about 55.9% (n=212) reported that they would continue with self-medication post-covid-19 pandemic. when asked about their opinion regarding self-medication and the outbreak, approximately 84.1% (n=280) reported that the pandemic had increased the desire for self-medication for the general public. on a positive note, 91.3% (n=304) would not advise other people to self-medicate. this study was conducted during the covid-19 pandemic to investigate the prevalence of selfmedication and associated factors among healthcare workers in kenya before and during outbreak. the prevalence of self-medication had increased from 36.2% before the outbreak to 60.4%, during the outbreak. these results were close to the findings from a similar study undertaken in nigeria (ea et al., 2006) . in the current study, an analysis was done to determine the prevalence of self-medication across cadres, and the nursing officers reported a prevalence of 32.8% during the outbreak. this finding is similar to a study conducted in brazil on the prevalence of self-medication among nurses (rotenberg, 2009 ). in the current study, several considerations for the preference of particular drugs for selfmedication were evaluated. the brand of the medicine, cost, and the manufacturing company were the primary considerations. this, too, has been found in similar studies (selvaraj and ramalingam, 2014) . the majority of the respondents took medicines for pain relief, more specifically headaches, migraine, fever, joint and muscle pains before and during the outbreak. these conditions are a common reason for self-medication (auta et al., 2012) . self-medication was significantly associated with the level of education as those with degrees were more likely to self-medicate both before and during the outbreak. these findings agree with similar studies (lópez jj, dennis r, 2009) , and this has been attributed to the vast knowledge on the medication as most medical graduates do possess a higher level of understanding of the over-the-counter drugs, including their prescription and side effects. of note was that some studies have given divergent results regarding this finding. a similar study (sharma et al., 2005) reported that self-medication was higher among respondents who had secondary education and below compared to those with advanced education. in the current study, gender was statistically significant. more female participants were likely to self-medicate before and during the outbreak. however, similar studies from other regions (bennadi, 2014; shankar et al., 2002) have shown that male healthcare workers are more likely to self-medicate than their female counterparts (belachew gutema et al., 2011; sawalha, 2007) . in this study, participants who engaged in physical activity were less likely to self-medicate both before and during the outbreak. this finding agrees with existing evidence on physical activity and self-medication (wijesinghe et al., 2012) . the study participants were all working in healthcare institutions where access to medical care was guaranteed as all the respondents had a medical insurance cover. however, this did not deter them from preferring self-medication. this study agrees with similar studies that have shown that open access to healthcare does not significantly reduce self-medication (ehigiator et al., 2013) . in addition, it was noted that work shifts triggered self-medication; those working at night were more likely to self-medicate both before and during the outbreak. similar studies have indicated that most healthcare workers on night shift tend to self-medicate as a result of unfavourable working conditions, and working for long hours with minimum rest, which may contribute to lassitude (rotenberg, 2009 ). the findings from multivariable logistic regression analyses showed that the respondents who undertook physical activity, worked during the day, and those who were healthy, correlated well with the prevalence of self-medication (p<.01). similar studies conducted in other regions have shown similar results (lei et al., 2018) . this study was restricted to healthcare workers who were currently actively involved in managing the covid-19 pandemic and had self-medicated 21 days preceding the interview. therefore, there is a possibility of recall bias. also, cross-sectional studies do not permit an establishment of a clear cause and effect. self-medication is a significant health issue, especially during covid-19 pandemic, and a refresher course in the form of continued medical education (cme) should be encouraged. awareness creation is also needed, not only to the healthcare workers but also to the general public; especially on the risks involved since the potential danger of self-medication might be underestimated during emergencies. there is need to undertake a study on how ethnic differences, and religious beliefs would influence self-medication among healthcare workers. this study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors there are no potential conflicts of interest (political, personal, religious, ideological, academic, intellectual, commercial or any other) that should be declared in relation to this manuscript. medicine vendors: selfmedication practices and medicine knowledge self-medication practices among health sciences students: the case of mekelle university self-medication: a current challenge health workforce perspectives of barriers inhibiting the provision of quality care in nepal and somalia-a qualitative study building a midwifery profession view project ladnaan-a sense of health and well-being view project health workforce perspectives of self medication practices among workers in a tertiary hospital in nigeria self-medication practices among dental, midwifery and nursing 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disease 2019 (covid-19): a perspective from china key: cord-289488-vyjhoa65 authors: machida, masaki; nakamura, itaru; saito, reiko; nakaya, tomoki; hanibuchi, tomoya; takamiya, tomoko; odagiri, yuko; fukushima, noritoshi; kikuchi, hiroyuki; amagasa, shiho; kojima, takako; watanabe, hidehiro; inoue, shigeru title: the actual implementation status of self-isolation among japanese workers during the covid-19 outbreak date: 2020-08-03 journal: trop med health doi: 10.1186/s41182-020-00250-7 sha: doc_id: 289488 cord_uid: vyjhoa65 background: self-isolation is an important personal protective measure in inhibiting the transmission of coronavirus disease 2019 (covid-19) as people carry out economic and social activities amid its spread. yet few studies have clarified the actual implementation status of self-isolation during an outbreak. this study aimed to reveal the actual implementation of self-isolation among japanese workers during the covid-19 outbreak and the factors inhibiting this measure. methods: this was a cross-sectional study based on an internet survey completed by 1,226 workers (60.0% men) living in 7 prefectures (i.e., tokyo, kanagawa, saitama, chiba, ibaraki, tochigi, and gunma) who were selected among registrants of an internet research company, between may 12 and 17, 2020. participants were asked whether they had experienced fever or other cold symptoms between february 17, 2020 and the date of the survey. those who responded affirmatively were asked where they had visited (e.g., hospital, work, and shopping for groceries or necessities) to clarify whether they had left the house within 7 days after symptom onset. we performed multivariate logistic regression analysis to clarify the relationship between going to work within 7 days after symptom onset and both sociodemographic factors and employment-related constraints. results: of the survey participants, 82 had experienced fever or other cold symptoms (6.7%). among these participants, 51 (62.2%) went to work within 7 days after symptom onset. a mere 17.1% practiced strict self-isolation. multivariate logistic regression analysis revealed that those living outside the metropolitan area (i.e., ibaraki, tochigi, and gunma), working as a company employee, and being unable to work from home were associated with going to work within 7 days after symptom onset. conclusions: the prevalence of strict self-isolation among participants who experienced cold-like symptoms during the covid-19 outbreak was extremely low, and 62.2% of these participants went to work within 7 days after symptom onset. this study highlights the need for further public awareness regarding self-isolation and countermeasures against factors that obstruct it. as of may 2020, the coronavirus disease 2019 (covid19) pandemic remains active. it is vital that personal protective measures are implemented by the public as a method to mitigate the epidemic of respiratory viruses such as covid-19, especially before a well-matched vaccine is widely available [1] . one personal protective measure recommended by the world health organization in the covid-19 pandemic is self-isolation [2] . self-isolation refers to voluntary separation or restriction of movement of ill persons in a designated room to prevent transmission to others in their own homes or elsewhere [3] . this method is effective in preventing individuals who have been infected from transmitting the virus to others [1] . many health authorities are recommending self-isolation during the covid-19 pandemic [2, 4, 5] . this includes the japanese ministry of health, labour and welfare that has been recommending the public practice of selfisolation, if a person develops a fever or other cold symptoms, since the earliest time of the outbreak [6] . most research on the practice of self-isolation by ordinary citizens have evaluated the intention to practice self-isolation and have reported the prevalence of self-isolation to be approximately 70-90% [7] [8] [9] [10] . in contrast, there are very few studies evaluating the actual status of self-isolation [11] . furthermore, previous studies have found employment characteristics, such as being unable to work from home, no guaranteed paid leave, and low income as factors inhibiting the practice of self-isolation [9, 12] , however to the best of our knowledge, none have explored factors obstructing self-isolation while looking at the actual status of self-isolation practices. as of may 2020, many countries including japan are beginning to relax restrictions placed on outings by various state of emergency declarations [13, 14] . self-isolation by ordinary citizens will be an important personal protective measure for public health as we resume social activities [15] . furthermore, self-isolation by workers will be of great importance, since there is a possibility that employment-related constraints which cannot be controlled by workers themselves may have a major impact on the implementation of self-isolation, and workers are likely to have more contact with co-workers due to long working hours. thus, this study aimed to clarify the actual implementation of self-isolation among japanese workers who experienced fever or other cold symptoms during the covid-19 outbreak and factors inhibiting this measure. this was a cross-sectional study utilizing data of the third wave of a longitudinal research which aimed to clarify implementing personal protective measures by ordinary citizens during the covid-19 outbreak. in the first wave survey of this longitudinal study on february 25, 2020, a total of 2,400 men and women aged 20 to 79 years (sampling by sex and 10-year age groups; 12 groups, n=200 in each group) who were living in 7 prefectures (i.e., tokyo, kanagawa, saitama, chiba, ibaraki, tochigi, and gunma), and who met the criteria to participate in this research were recruited from 8,156 registrants, of a japanese internet research service company called myvoice communication, inc., which had approximately 1.12 million registered participants as of january 2020. detailed methods about sampling have been reported elsewhere [10] . the company reached out to these 2400 potential respondents by e-mail, to participate in the third wave research on may 12. the questionnaires were placed in a secured section of a website, and potential respondents received a specific url in their e-mail. participation was voluntary, and participants responded to the questionnaire by accessing the specified url. the response cutoff date was may 17. reward points valued at 50 yen were provided as incentives for participation (approximately 0.5 us dollars as of may 2020). the japanese ministry of health, labour and welfare has recommended that ordinary citizens practice selfisolation if they have fever or other cold symptoms [6] . therefore, the present study evaluated the self-isolation status of individuals who experienced fever or other cold symptoms regardless of whether covid-19 was diagnosed (in this study, such symptoms and participants are referred to as having 'cold-like symptoms' and 'participants who have experienced cold-like symptoms', respectively). the recommended self-isolation period was for 7 days after symptom onset according to guidelines of the japanese society of travel and health and the april 4 interim guidance from the us centers for disease control and prevention [16, 17] . participants were first asked, "have you experienced fever or other cold symptoms since february 17, 2020?" the date february 17, 2020, was when the japanese ministry of health, labour and welfare requested citizens to begin practicing self-isolation [6] . participants who responded "yes" were then asked whether they had gone out to various places (e.g., hospital, work, shopping for groceries or necessities) within 7 days of symptom onset, and responded with either a "yes" or "no"). in the first wave survey, participants stated their sex, age, underlying diseases which included heart diseases, respiratory diseases, kidney diseases, diabetes, and hypertension (yes/no), and residential area (metropolitan area [i.e., tokyo, kanagawa, saitama, and chiba]/nonmetropolitan area [i.e., ibaraki, tochigi, and gunma]). in the third wave survey, participants stated their occupation (company employee, self-employed, part-time job, government worker, homemaker, unemployed, student, other) and responded to the following about employment-related constraints that may inhibit the practice of self-isolation: can work from home (yes/no), will not be paid if leave is taken (yes/no), and may be terminated if leave is taken (yes/no) [12] . the research company also provided categorized data as follows: living arrangement (with others/alone), educational attainment (university graduate level or above) and household income level (< 5 million yen or ≥ 5 million yen). as this study aimed to reveal the actual implementation status of self-isolation practices among workers, statistical analyses included only subjects who selected 'company employee', 'self-employed', 'part-time job', 'government worker', or 'other' for their occupation. participants who had experienced cold-like symptoms and responded that they had not gone anywhere or had gone only to the hospital within 7 days after symptom onset were classified as practicing 'strict self-isolation', while those who went out for reasons other than hospital visits were classified as 'not practicing strict self-isolation'. the total number of persons and percentages were calculated for each of these groups, as well as for each location mentioned. participant characteristics were compared using the chi-square test, fisher's exact test, or t-test between participants who did or did not experience cold-like symptoms, and among those who experienced cold-like symptoms, whether or not they did or did not go to work within 7 days after symptom onset. to clarify the association between going to work within 7 days of symptom onset and each sociodemographic factor and employment-related constraints, a multivariate logistic regression analysis was performed. the participants of this logistic regression analysis were those who responded that they experienced fever or other cold symptoms since february 17, 2020. the dependent variable was set as a dichotomous variable coded as "1" if the participant who experienced fever or other cold symptoms went to work within 7 days of symptom onset, and "zero" otherwise. the independent variables included sex, age (≥ 65 years old/< 65 years old), underlying diseases (yes/no), residential area (metropolitan area/ nonmetropolitan area), living arrangement (with others/alone), educational attainment (university graduate level or above/below), household income level (< 5 million yen/≥ 5 million yen), occupation (company employee/self-employed/part-time job/ government worker, or other), ability to work from home (yes/no), absence of paid leave (yes/no), and possibility of termination if leave is taken (yes/no). statistical analyses were performed using ibm spss statistics for windows, version 26 (ibm japan, tokyo, japan). two-sided p values less than 0.05 were considered to be statistically significant. the internet research company reached out to 2385 participants, after excluding participants who were not registered with the company at the time of the third wave survey (n=15), and 2,200 participants responded to the questionnaire. of the 2,200 potential respondents, 974 were excluded for the following reasons: they were homemakers, unemployed, or students (n=810), and the data provided by the research company were incomplete (n=164). therefore, the analysis set consisted of 1,226 participants. of the analysis set, 82 participants (6.7%) experienced cold-like symptoms between february 17, 2020, and the day of the survey. no participant reported that they were diagnosed with covid-19. table 1 shows the participant characteristics. compared to participants who did not experience cold-like symptoms, the proportion of participants having underlying diseases and not being paid if leave is taken was significantly higher among participants who experienced cold-like symptoms. table 2 shows the behavior of participants who experienced cold-like symptoms within 7 days of symptom onset amid the covid-19 outbreak. of the 82 participants who experienced cold-like symptoms, a mere 17.1% practiced strict self-isolation for the 7-day period after onset. the most common locations for outings among participants who did not practice self-isolation were the workplace and shops for groceries or necessities with 51 (62.2%) of these participants going to work within 7 days after symptom onset. table 3 shows the characteristics of participants who experienced cold-like symptoms categorized by whether the patient did or did not go to work within 7 days after symptom onset. among participants who experienced cold-like symptoms and went to work within 7 days after symptom onset, although the differences were not statistically significant, the proportion of participants who were unable to work from home was higher than participants who were able to do so. table 4 shows the association between going to work within 7 days after symptom onset and each sociodemographic factor and employment-related constraints among participants who experienced fever or other cold symptoms (n=82). according to multivariate logistic regression analysis, being a company employee, and being unable to work from home were significant factors for those who went to work within 7 days after symptom onset (being a company employee; odds ratio [or]: 25.81, 95% confidence interval [95% ci]: 2.23-298.31, unable to work from home; or: 4.22, 95% ci: 1.02-17.43), while living in a metropolitan area was a significant factor for not going to work (living in a metropolitan area; or: 0.06, 95% ci: 0.00-0.79). we set out to determine the actual implementation status of self-isolation among japanese workers during the covid-19 outbreak and to clarify the factors that may inhibit the implementation of self-isolation. only 17.1% of participants who experienced cold-like symptoms practiced strict self-isolation within 7 days after symptom onset, while 62.2% went to work during this period. multivariate logistic regression analysis indicated that being unable to work from home, living outside a metropolitan area, and being a company employee may be factors associated with people going to work during the recommended self-isolation period. the majority of previous research on self-isolation have evaluated the intention to practice self-isolation and results have shown that the prevalence of selfisolation by ordinary citizens was approximately 70visited their workplace, school, or other potentially crowded settings within 7 days after diagnosis [11] . this is consistent with the findings of the present study in which the prevalence of strict self-isolation table 4 the association between going to work within 7 days after symptom onset and each sociodemographic factor and employment-related constraints among participants who experienced cold-like symptoms (n=82) was extremely low in the majority of participants who experienced cold-like symptoms as many of them went out to work or shop within 7 days after symptom onset. previous researches evaluating the intent to self-isolate may be overestimating the prevalence of self-isolation due to social desirability bias, in which respondents answered in such a way that they would be viewed favorably [18] . our results suggest that most japanese workers do not practice strict self-isolation during a pandemic. further public awareness activities concerning the importance of self-isolation and promoting commitment to its practice are essential. the employment-related constraint of being unable to work from home and the sociodemographic factors of living outside a metropolitan area, and being a company employee were associated with participants going to work during the recommended self-isolation period in the present study. in two studies of self-isolation conducted in the united states, the employment characteristics of being unable to work from home and not being paid while on leave, as well as having a low income, were found to be factors impeding self-isolation [7, 12] . a separate study by bodas et al. concerning intention to self-isolate during the covid-19 outbreak in israeli adults reported that guaranteed income during self-isolation increased the intention to practice self-isolation [9] . thus, our finding that being unable to work from home was a factor obstructing self-isolation is indeed consistent with these previous studies, however in contrast, we did not find statistically significant associations between going to work within 7 days after symptom onset and guaranteed income while on leave, or relation with income levels. as the sample of participants for the multivariate analysis in this study was small (n= 82), we would like to be reserved when drawing conclusions, yet it seems likely that the impact of employment characteristics and sociodemographic factors on self-isolation practices differs depending on cultural and ethnic backgrounds. there is a tendency in japanese culture to portray a responsible worker as someone who actually goes into the workplace to work. it is further probable that if workers were given the option of working from home when they are feeling unwell, the practice of self-isolation would increase voluntarily, thereby preventing the spread of infection. aside from work, participants also commonly went out during the recommended self-isolation period to shop for groceries and necessities. during the current covid-19 pandemic, the european centre for disease prevention and control recommends that individuals practicing self-isolation call on a friend, neighbor, or health-care worker to purchase groceries and the like on their behalf [19] . such efforts are also likely to improve the status of self-isolation practices. there are some limitations that should be considered in our study. the most important point is the fact that in this study, participants were recruited from people enrolled in a single internet research company, and thus, the results may have been affected by selection bias. relatively little is known about the characteristics of people in online communities [20] . furthermore, some sociodemographic factors (e.g. age, sex and residential area) of the participants in this study were different from that of the japanese population [21] , since the sociodemographic factor of the research company registrant differs from that of the general japanese population. second, this study has a small sample of participants who experienced cold-like symptoms (n=82). the number of independent variables may be slightly large considering the sample size [22] . a larger-scale survey will be necessary to further clarify the factors obstructing actual self-isolation practices. third, concerning the actual status of self-isolation practices, our survey asked participants about symptom onset between february 17, 2020, and the day of the survey, however there were major changes in the spread of covid-19 during this time. as self-restraint requests by the japanese government also escalated during this time [23, 24] , these changes may have influenced the status of self-isolation practices by workers. as we did not ask the participants about the date of onset, the influence of such changes is unclear. fourth, since we used the questionnaire to assess symptom onset and behavior within 7 days after symptom onset, these results may be affected by recall bias [25] . fifth, the participants in this study participated in a longitudinal research which aimed to clarify implementing personal protective measures by ordinary citizens during the covid-19 outbreak from february 25, 2020. participation in this longitudinal study may have influenced the participants' awareness of personal protective measures, thereby possibly affecting the implementation of self-isolation. finally, the results, especially the prevalence of self-isolation, may only be directly applied to japanese populations. in the case of other populations with different cultural, ethnic, and geographical backgrounds, the prevalence of personal protective measures may vary greatly when compared with those reported in the present survey. despite these limitations, to the best of our knowledge, this study is the first to reveal the actual status of self-isolation practices of workers during the covid-19 outbreak. the prevalence of strict self-isolation among participants who experienced cold-like symptoms during the covid-19 outbreak was extremely low, and 62.2% of these participants went to work within 7 days after symptom onset. providing workers with the option to work from home may be an effective means to increase the prevalence of self-isolation. this study emphasizes the need for further public awareness regarding self-isolation and measures to counter the factors that impede this important measure to prevent transmission of covid-19. abbreviations covid-19: coronavirus disease 2019 community mitigation guidelines to prevent pandemic influenza -united states protecting yourself and others from the spread covid-19 european centre for disease prevention and control. guide to public health measures to reduce the impact of influenza pandemics in europe european centre for disease prevention and control. guidelines for the use of non-pharmaceutical measures to delay and mitigate the impact of 2019-ncov centers for disease control and prevention. what to do if you are sick japanese ministry of health, labour and welfare. prevention measures against coronavirus disease 2019 (covid-19) public response to community mitigation measures for pandemic influenza self-reported anticipated compliance with physician advice to stay home during pandemic (h1n1) 2009: results from the self-isolation compliance in the covid-19 era influenced by compensation: findings from a recent survey in israel adoption of personal protective measures by ordinary citizens during the covid-19 outbreak in japan behavior of adult influenza patients during the 2009 pandemic after outpatient clinic presentations at a hospital in tokyo. japan employment and compliance with pandemic influenza mitigation recommendations japanese ministry of health, labour and welfare. basic policies for novel coronavirus disease control by the government of japan (summary) our plan to rebuild: the uk government's covid-19 recovery strategy an updated estimation of the risk of transmission of the novel coronavirus (2019-ncov) japanese society of travel and health. novel coronavirus disease 2019 (covid-19) infection prevention guideline for workplace discontinuation of isolation for persons with covid-19 not in healthcare settings interim guidance two-component models of socially desirable responding european centre for disease prevention and control. isolate at home if sick researching internet-based populations: advantages and disadvantages of online survey research, online questionnaire authoring software packages, and web survey services population census a simulation study of the number of events per variable in logistic regression analysis japanese ministry of health, labor and welfare. expert meeting on the novel coronavirus disease control analysis of the response to the novel coronavirus (covid-19) and recommendations (exerpt). 2020 declaration of a state of emergency in response to the novel coronavirus disease recall bias in epidemiologic studies publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we express our sincere gratitude to all participants who enrolled in this study. all authors contributed to the study conception and design. data collection and analysis were performed by mm, si, and in. the first draft of the manuscript was written by mm and si. all authors were involved in the review of previous versions of the manuscript. all authors have read and approved the final manuscript. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. this study was approved by the ethics committee of tokyo medical university, tokyo, japan (no: t2019-0234). informed consent was obtained from all respondents. the authors declare that they have no competing interests. 1 key: cord-032627-i3u9np23 authors: amir-behghadami, mehrdad; tabrizi, jafar sadegh; saadati, mohammad; gholizadeh, masoumeh title: psychometric properties of the iranian version of self-care ability scale for the elderly date: 2020-09-22 journal: bmc geriatr doi: 10.1186/s12877-020-01775-6 sha: doc_id: 32627 cord_uid: i3u9np23 background: measuring self-care ability in elderly people needs specific instruments. the self-care ability scale for elderly (sase) is one of the common instruments used for assessing self-care ability. the aim of this study was to assess the psychometric properties of the sase among iranian elderly population. methods: this cross-cultural adaptation study was carried out at shahid chamran and shadpour health complex in tabriz, iran. the forward-backward procedure was applied to translate the sase from english into persian. then, it was completed to 220 elderly people. a systematic random sampling method was used for sampling. content validity was calculated through modified kappa coefficient (modified cvi) based on clarity and relevance criteria. reliability was measured by internal consistency and test-retest analysis. the construct validity also was assessed using exploratory factor analysis (efa). all the statistical analyses were performed using spss 21 statistical software package. results: the mean of self-care ability was 61.14 ± 21.08. the cvi and modified kappa were 0.91 and 0.92 for relevance and clarity, respectively. the cronbach’s alpha coefficient was 0.73 and intra-class correlation coefficient was 0.97. the results of efa revealed a three-factor solution (‘ability to take care of personal responsibility’, ‘ability to take care for the goals’, and ‘ability to take care of the health’) that jointly explained for 64.61% of the total variance. conclusion: results of the study showed that the iranian version of the sase has good psychometric properties and can be used in assessing the self-care ability of elderly people. which means 6% of the total population of iran is over 60 years old [1] . aging occurs in all main regions of the world; on the whole, proportion of the people over 60 years old was 9% in 1994 but increased up to 12% in 2014. and, it is expected to hit 21% in 2050 [6] . the growing ageing population creates demands on the healthcare system to strengthen the older person's self-care ability and to promote healthy ageing [7] . although aging is often associated with a reduction in physiological, cognitive and functional abilities, healthy aging does not mean the absence of restrictions but a level of health and compliance with the aging process that is acceptable to people. the literature emphasizes factors that may be positively attributed to healthy aging. farquhar mentioned the dimensions of quality of life that are often mentioned by older people: family, social relationships, health (physical), mobility / ability, activities, happiness, youthfulness, and home environment [8] . factors relevant to the elderly health and self-care can be used for regular assessment to support and promote healthy ageing [7] . self-care ability is a determinant factor in managing the daily lives of the elderly [9] . self-care is taken as a personal care, which older people do for themselves to maintain, restore or promote their health [10] . self-care refers to the individual's ability to perform self-care or selfmanagement activities that has achieved the balance between their abilities and the existing needs for self-care and is influenced by factors such as age, level of development, life experiences, and cultural context and health conditions. self-care ability is different in different stages of development, as well as in acute or chronic conditions of health [11] . however, high self-care ability can also be affected by health (physical and mental), good habits (for example, a healthy lifestyle such as being active, having a satisfactory social relationship), self-esteem, and self-care ability [12] . it is also a major source of health and wellbeing for the elderly, especially when they live in the home [13] . salehi et al. reported that indolence is the most significant obstacle for not being engaged in physical activities [14] . similarly, they reported in another study that some reasons for not being active are fear of falling, lack of motivation, unsafe physical environment, extensive tiredness, illness, and not having a companion to do physical activities [15, 16] . a study in iran has reported that the demand for health care in elderly people is 3 times more than the non-elderly population, as the age of the elderly increases, this demand also increases [17] . however, health centers do not respond to the increasing demand of this population. therefore, increasing the responsibility for self-care allows the elderly to be less dependent on them and improve their quality of life [1] . rechel et al. show that health systems can support elderly people by encouraging them to have self-care [18] . self-care increases self-promoting behaviors, or the ability of individuals to self-manage chronic diseases [19] . therefore, the self-care ability of elderly people should be turned into international issues and be important for health professionals around the world. using instruments to assess self-care is a starting point for encouraging older people to take care of themselves [20] . health care providers need to know the self-care ability of individuals for identifying people at risk and developing their self-care programs at the individual and social level [21] . therefore, it is essential that the reliability and validity instruments be designed to measure self-care [22] . in addition, using of a viable and reliable instrument, which measures self-care, can stimulate further research on health promotion and self-management of chronic diseases. such studies can help people in their care activities to manage their chronic illnesses and preventing it [19] . the original swedish version of the sase has been tested, and there is evidence to show its validity and reliability [23, 24] . in addition, it is short (17 questions) and easy to complete. considering the growth of the aging population in iran and the need to provide health, medical and social services in accordance with their needs; measuring self-care ability in the elderly is a necessary issue. there are few instruments specifically for those with heart failure [25] and diabetic patients [26] not for general elderly population. therefore, the purpose of study was to assess the psychometric properties of the iranian version of the sase in order to provide a standard, valid, and reliable instrument for measuring the elderly's self-care ability. in recent years, the increase in the number of multicultural studies has urged the need to adapt scales to be used in other languages. hence, depending on different cultures, the scales should be culturally modified and adapted. regarding this point, cross-cultural adaptation must be applied as the study design. this consists of translation, adaptation, calculation of validity, and reliability. the present study was also a cross-cultural adaptation conducted in shahid chamran and shadpour health complexes affiliated to tabriz university of medical sciences in tabriz, iran 2015. health complexes were launched after implementation of the health system reform plan in iran, which assumed to provide integrated care in a defined area under district health center policies and regulations. each health complex consists of 4-5 health centers that cover 10,000 to 30,000 people. health centers generally provide preventive services and, if necessary, refer individuals to more specialized services to the health complex clinics. sample framework for selecting people was based on the registered records health. as the samples of this study, 220 older people who attend these complexes were recruited. the sample size of 220 people was calculated using g-power software. sample allocation to each complex was done in the same way. an a priori g-power analysis was performed. thus, considering independent samples t-test (two tailed) with 99% power and alpha = 0.01 significance level, we estimated an overall sample size of 220 older people for detecting differences between two independent means with effect sizes (d = 0.66). the participants were selected using a systematic random sampling method according to the following inclusion criteria: age over 60 years; ability to communicate; having a stable condition; and willingness to take part in this study. people, who were not permanent residents of shahid chamran and zafaraniyeh or who suffered from acute disease, were excluded from this study. the sase, as a self-reporting instrument, measures selfcare ability among older people [25] . in fact, three versions were available in chinese, italian and swedish. this instrument consists of two parts: the first part, the demographic characteristics of the elderly, and the second part consists of 17-item likert scale that highlights areas of particular importance to self-care for the elderly, i.e. daily life activities, welfare, power, desires, determination, loneliness and wear clothes. the accountability scale of each item is between 1 "totally disagree" to 5 "totally agree". a higher overall score indicates a higher self-care ability. the construct of self-care ability is considered as a necessary condition for self-care, and when this ability is exercised, self-care actions are achieved. the internal structure of sase includes "ability for care of repertoire", "ability for care of goal", and "ability for care of well-being" [23, 24] . the permission to translate the english version of the sase was obtained from the main author (söderhamn) . then, the forward-backward translation and cultural adaptation was performed at several steps. a professional translator translated the instrument into persian and another professional translator translated the iranian version back into english. both translators performed the translation process separately. after the completion of translation, an expert panel consisting of two elderly specialists and three elderly nursing compared the original english version with back translation and following cultural and linguistic adaptation, pre-final iranian version of the sase was prepared. then, this version was examined among ten older people and modifications were done based on their feedback. at last, it was developed and used in this study for further psychometric assessment. descriptive statistics were used to describe the characteristics of the sample and several statistical analyses were applied to assess the psychometric properties of the iranian version of sase. the content validity was assessed through modified kappa by means of qualitative and quantitative approaches [27] . in this regard, the iranian version of the sase was sent to 10 specialists with sufficient clinical experience and theoretical knowledge about nursing and self-care. the fields of the experts were health education and promotion, geriatric health, community health, psychology, nursing, and epidemiology. in the qualitative approach, experts were requested to provide their own ideas for improving its quality. and in the quantitative approach, in order to calculate the cvi and modified kappa coefficient basis on relevance and clarity, each item was ranked on a four-point likert scale based on views of the experts [27, 28] . the reliability was assessed using internal consistency and the test-retest reliability method. the internal consistency was measured by the coefficient cronbach's alpha, which varies from 0 to 1, and values equal to or > 0.70 for a scale show a satisfactory internal consistency [29] . in order to estimate the test-retest reliability, the intra-class correlation coefficients (iccs) during a twoweek interval were calculated among 30 older people for total scale and each subscale. the following categories were chosen for the interpretation of agreement levels: 00-0.2 as small, 0.21-0.40 as fair, 0.41-0.60 as moderate, 0.61-0.80 as remarkable and 0.81-1 as approximately perfect [30] . prior to efa, kaiser-meyer-olkin (kmo) was calculated to ensure that the sample size was adequate. kmo shows values between 0 and 0.49 as unacceptable, 0.5-0.7 as mediate; 0.7-0.8 as good, 0.8-0.9 as great, and > 0.9 as excellent [31] . efa was performed using the principal component analysis with varimax solution [32] . since we could not find a clear relationship between the items in the questions and the construct to be measured, we needed an exploratory factor analysis. in other words, we were not sure which items measured which structures. therefore, because of this suspicion, we used exploratory factor analysis [33] . to select the factors, an eigenvalue greater than 1 and a factor loading equal to or greater than 0.4 were used. all the statistical analyses were performed using spss 21 statistical software package. the mean age of respondents was 68.65 ± 7.17 and 52.3% of them were male. in addition, 52.3% of the elderly were married, 51.8% of them were illiterate, 39.1% of them had social security insurance, and 48.2% of them had complementary insurance. additionally, 56.4% of them were living with their spouses and income source of 41.8 of them was pension. the mean of self-care ability in urban living the elder people of tabriz was 61.14 ± 21.08 (table 1) . in the qualitative content validity, the iranian version of the sase was improved by the experts' comments. the result of quantitative content validity indicated that the cvi and modified kappa were 0.91 and 0.91 for relevance and 0.92 and 0.92 for clarity, respectively. the cvi and modified kappa have been illustrated for each item (table 2) . the cronbach's alpha coefficient for overall scale, subscale 1, subscale 2, and subscale 3 was 0.73, 0.7, 0.71, and 0.75, respectively. test-retest reliability for overall scale, subscale 1, subscale 2, and subscale 3 (assessed by icc) was 0.96, 0.92, 0.85, and 0.97, respectively. the kmo indicated that the sample size was adequate for factor analysis (kmo index = .757). three factors were identified with an eigenvalue greater than one that jointly accounted for 64.61% of variance observed. the factor loadings were as follows: factor 1 (ability to take care of personal responsibility) including 8 items (item 1, 2, 3, 4, 5, 13, 14, and 17). factor 2 (ability to take care of goals) including 7 items (item 6, 7, 8, 9, 11, 12, and 16) . factor 3 (ability to take care of health) including 2 items (item 10 and 15). (table 3 ) the sase has been assessed and used in some studies among older people [23, 24] . measuring self-care ability in the elderly people plays an important role in improving their quality of life. in general, the results of the current study demonstrated that iranian version of the sase had a valid and reliable instrument for assessing self-care ability in the iranian older population. content validity is an essential component of psychometric properties, which must be done independent of the translation phase. during the qualitative content validity, only a few points with trivial ambiguity were determined by the experts and were modified accordingly [1] . in the quantitative content validity, the cvi and modified kappa were also assessed and the calculated values were at a high level. therefore, the iranian version of the sase indicated good content validity. in studies by söderhamn et al. (1996) and tomstad et al. (2013) , the content validity was not calculated [22, 23] . the internal consistency of scale was satisfactory (alpha 0.73), indicating that the instrument is homogeneous. the obtained alpha in this study is higher than the reported alpha in the swedish study (alpha 0.68) [9] ; however, it is less than the reported alpha in the norwegian and swedish studies, respectively (alphas 0. 88 and 0.85) [22, 23] . in general, a satisfactory level of internal consistency was considered a cronbach's α ≥ 0.7 for scale and all of the subscales. the test-retest reliability of the sase with a two-week interval was found to have almost perfect stability. using the intra-class correlation coefficients test, all subscales reported a high correlation (≥ 0.8). in a study by gao et al. (2017) , the test-retest reliability was (≥ 0.8) similar to this study [20] ; however, it had not been measured in studies by söderhamn et al. (1996) and tomstad et al. (2013) [22, 23] . the results kmo confirmed that the sample size was adequate for factor analysis. the efa showed a threefactor solution to the iranian version of the sase, which was similar to the study conducted by olle söderhamn (2001) and the study done by gao et al. (2017) , a threefactor solution including components such as repertoire (factor 1), goal (factor 2), and environment (factor 3). however, the three factors efa found in this study differ from the five factors efa reported in study söderhamn et al. [20, 23] . this five-factor solution accounted for 70.2% of the variance. factor 1 represented the ability of care (responsibility and environment). factor 2 represented the ability to care (purpose and responsibility). factor 3 represented the goals and ability to take care of responsibility. factor 4 represented the ability to take care (responsibility), and factor 5 represented the ability to take care of the goals. study finding indicated a threefactor solution that totally explained 64.61% of the variance. this study showed that the iranian version of the sase has good psychometric properties to be used. therefore, it will help nurses and health care providers in different health care centers such as hospitals, primary healthcare centers, and rehabilitation centers to evaluate elderlies' self-care ability. this study had some limitations and strengths. firstly, a major problem with the translation is that the english version was used for translation. the most accurate method was to use swedish to persian translation. however, professional translators translated the swedish version of the sase according to the recommended procedure in english (brislin 1970). moreover, the rigorous translation methods used in the present study were used to obtain a good translation of the english version of sase to persian. secondly, it is likely that study results may not be completely generalizable to all the elderly, since it was carried out on older people referring to health complexes. hence, other scholars should assess the validity and reliability of the instrument and then use it in accordance with their needs. finally, we have not tested concurrent validity. therefore, it is suggested that further research be conducted to include other validated questionnaire such as physical activity scale for elderly (pase) [15] to provide stronger support for concurrent validity. independent expert panels for translating and evaluating content validity of scale are strength of the study. self-care ability of older people living in urban areas of northwestern iran healthy ageing-nursing older people exercise dose-response effects on quality of life and independent living in older adults leg extensor power and functional performance in very old men and women muscle strength and functional capacity in 78-81-year-old men and women priorities of active aging policy in iran. depiction of health perspectives of health and selfcare among older persons-to be implemented in an interactive information and communication technology-platform in their own words: a model of healthy aging the self-care ability scale for the elderly self-care and multiple sclerosis: a view from two cultures nursing: concepts of practice self-care ability among home-dwelling older people in rural areas in southern norway self-care as a health resource of elders: an integrative review of the concept physical activity among a sample of iranians aged over 60 years: an application of the transtheoretical model cultural adaptation and psychometric adequacy of the persian version of the physical activity scale for the elderly (p-pase) physical activity in iranian older adults who experienced fall during the past 12 months elderlies and medical services: demand and utilization in tehran. payesh (health monitor) how can health systems respond to population ageing jaber aaf. reliability, validity and factor structure of the appraisal of self-care agency scale-revised (asas-r) reliability and validity of the chinese version of the self-care ability scale for the elderly ability for self-care among home dwelling elderly people in a health district in sweden testing two self-carerelated instruments among older home-dwelling people in norway validity of two self-care instruments for the elderly health and the internal structure of the self-care ability scale for the elderly (sase) psychometric properties of the 9-item european heart failure self-care behavior scale using confirmatory factor analysis and rasch analysis among iranian patients self-care ability of diabetic patients referring to tabriz university of is the cvi an acceptable indicator of content validity? appraisal and recommendations developing and validating an instrument to assess nonhospital health centers' preparedness to provide initial emergency care: a study protocol the use of cronbach's alpha when developing and reporting research instruments in science education the measurement of observer agreement for categorical data reliability and validity of the persian version of templer death anxiety scale-extended in veterans of iran-iraq warfare exploratory factor analysis: a users' guide assessing the fear of covid-19 among different populations: a response to publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations thanks for the financial support provided by the student research committee (src) of tabriz university of medical sciences. we would like to thank all the elderly who participated in the present study. in addition, the authors thank professor ulrika söderhamn of the university of agder, grimstad, norway for her assistance in editing and modifying this manuscript. authors' contributions mab, jst, and ms contributed in study design, tool development and validation. mab and ms contributed in data collection and management. mab, jst and ms conducted data analyses and interpretation. mab, ms and mg wrote the first draft of the present manuscript. all authors critically reviewed and provided comments to improve the content of the written manuscript. they also read and approved the final version of the manuscript. this article was extracted from a part of mehrdad amir-behghadami's b.sc. dissertation in health care management, which was approved and financially supported by student research committee (src) of tabriz university of medical sciences (grant number: 62122). the funding body had no role in making the decision to design of the study; collection, analysis, and interpretation of data; nor writing the manuscript. the funder only provided funding for conducting the study. the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. this study was part of an approved study in the research ethics committee of tabriz university of medical science (ethical confirmation number; ir.tbzmed.rec.1397.145). written informed consent was obtained from all the participants of the study during assessing. not applicable. the authors declare that they have no competing interests. key: cord-307543-piust0s6 authors: oh, hyang soon title: knowledge, perceptions, and self-reported performance of hand hygiene among registered nurses at community-based hospitals in the republic of korea: a cross-sectional multi-center study date: 2018-05-14 journal: j prev med public health doi: 10.3961/jpmph.17.188 sha: doc_id: 307543 cord_uid: piust0s6 objectives: to assess the nurses’ hand hygiene (hh) knowledge, perception, attitude, and self-reported performance in smalland medium-sized hospitals after middle east respiratory syndrome outbreak. methods: the structured questionnaire was adapted from the world health organization’s survey. data were collected between june 26 and july 14, 2017. results: nurses showed scores on knowledge (17.6±2.5), perception (69.3±0.8), self-reported hh performance of non-self (86.0±11.0), self-reported performance of self (88.2±11.0), and attitude (50.5±5.5). hh performance rate of non-self was y(1)=36.678+ 0.555x1 (hh performance rate of self) (adjusted r(2)=0.280, p<0.001). the regression model for performance was y(4)=18.302+0.247x(41) (peception)+0.232x(42) (attitude)+0.875x(42) (role model); coefficients were significant statistically except attitude, and this model significant statistically (adjusted r(2)=0.191, p<0.001). conclusions: advanced hh education program would be developed and operated continuously. perception, attitude, role model was found to be a significant predictors of hh performance of self. so these findings could be used in future hh promotion strategies for nurses. health care-associated infections (hais) critically impact patient outcomes, increase hospital costs, and extend hospital pissn 1975-8375 eissn 2233-4521 stays [1] . at any given time, about 1 in 25 inpatients has an hai. this leads to the loss of tens of thousands of lives and costs the us health care system billions of dollars annually [2] . the primary transmission route of pathogens between patients in hais is via health care workers (hcws)' hands [3] . thus, hand hygiene (hh) is the single most important factor for preventing hais [1] . proper hh among hcws is one of the foremost techniques for reducing hais [1, 2] . however, the reported rates of hh performance among hcws are low, ranging from 18.3 to 68.0%, which is insufficient to satisfactorily prevent hais [1, 4] . during the middle east respiratory syndrome (mers) outbreak from may 20 to july 28, 2015 in the republic of korea (hereafter korea), there were 186 confirmed mers cases nationwide [5, 6] . we learned several important lessons from the mers outbreak, including that hh is the key to infection control and prevention. thereafter, various types of educational initiatives, campaigns, and training about hh have been implemented nationally, ranging from large cities to small-tomedium cities. in korea, infection control programs have been developed and implemented at university-affiliated hospitals in large cities, and these programs have spread to hospitals in small-tomedium cities [7] . studies of hh performance and knowledge among hcws have been conducted in larger hospitals with good resources for hh [8] [9] [10] . however, few studies have investigated knowledge and perceptions of hh among hcws in small-to-medium hospitals with relatively limited resources. because of their frequent contact with patients, nurses' proper execution of hh plays an especially important role in the prevention of hais, and nurses should therefore be provided with essential and up-to-date hh information. it has also been established that nurses' knowledge, perceptions, and attitudes about hh influence their hh performance [11] [12] [13] . as such, this study was conducted to assess the status of knowledge, perceptions, and performance of hh among nurses in community-based hospitals in a small-to-medium-sized city in an urban region in korea after the mers outbreak, to identify the factors that influenced their knowledge, perceptions, and performance, and to identify relationships among their knowledge, perceptions, and performance. a cross-sectional design was used to administer a self-reported questionnaire, which took approximately 20 minutes to complete. before the start of the study, the author contacted the hospital directors to explain the purpose of the study and to obtain permission for recruitment. the enrolment criteria were hospitals that were affiliated with teaching hospitals and permitted nurses to participate voluntarily in this study. finally, 5 community-based hospitals affiliated with teaching hospitals located in a small-to-medium-sized city in the south jeolla province of korea were enrolled in this study. we performed a power analysis using g*power version 3.1.9.2 (franz faul, universitat kiel, germany) to determine that a sample size of 270 would be required to achieve a power of 0.80 with an effect size of 0.15 (a medium effect size for multiple correlations) with an alpha of 0.05. a convenience sample of registered nurses (rns) was recruited from the 5 hospital study sites. the hospitals fully understood the purposes of the study and permitted voluntary recruitment; subjects' participation was voluntary and anonymous. questionnaires were delivered directly to, and later collected from, each hospital. data were collected from june 26 to july 14, 2017. a total of 300 questionnaires were distributed and 293 were returned (response rate, 97.7%). after excluding incomplete questionnaires, 289 questionnaires were used for the analysis. the questionnaire included 4 domains: (a) hh knowledge, (b) hh perceptions, (c) hh attitudes and role models, and (d) participant demographics and hospital characteristics. the knowledge domain (a) was adapted from the 2009 revision of the world health organization (who) hand hygiene knowledge questionnaires for health-care workers, which are composed of questions about the main route of transmission of germs, sources of hais, the timing of hh to prevent transmission of germs to patients or to other healthcare workers, knowledge about handwashing and alcohol-based hand rubs, knowledge about hh methods for clinical situations, and practices for increasing the prevalence of hh [14] . the 25 items included multiple-choice, true/false, and yes/no (coded as right answer=1, wrong answer=0) items, with a total score range of 0-25 points (table s1 ). the perceptions domain (b) was also adapted from the who questionnaire to identify perceptions and performance [15] . three questions (b2, b3, and b4 in table s2 ) were excluded from the total score because they reduced the reliability of the questionnaire (cronbach alpha, 0.729 with all questions; 0.932 after exclusion). eleven of the 16 items were on a 1-to 7-point scale from 'not effective' to 'very effective', or 'very low' to 'very high', with a total score range of 11-77 points. question b1 was used to assess self-reported hai rates. two other questions (b5 and b11) were analysed separately as indicators of the self-reported hh performance of non-self and self. the attitudes and role models domain (c) was adapted from hand hygiene knowledge and performance a previous study [8] . it was a self-report questionnaire consisting of 8 items on a 1-to 7-point scale from 'not effective' to 'very effective' [8] . the total scores ranged from 8 to 56. hh role models were assessed with 7 items on a 1-to 7-point scale from 'do not agree' to 'strongly agree', with a total score range of 7-49 points. a higher score in each domain indicated greater knowledge, more positive perceptions, more frequent performance, better attitudes, and higher scores for role models, respectively. the who-based questions were translated into korean and a pilot study was conducted from june 20 to 21, 2017, during which the translated items were reviewed by nursing professors and rns to assess the content validity and to refine a checklist. pilot study participants were asked to comment on whether the questionnaire items adequately sampled each domain; the questions were accurate, clear, and easy to understand; the instructions were clear and complete; and any of the questions or statements might lead to discord. the suitability of the questionnaire for use was confirmed by the pilot study. participants' time to complete the questionnaire was recorded and within-domain reliability was calculated. demographic variables included participants' age, sex, religion, marital status, education level, clinical work experience (years), department, and position. hospital characteristics included the type of hospital, number of beds, hh guidelines, presence of an infection control department (icd), presence of an infection control nurse (icn), number of hh sinks, number of alcohol-based hand rubs, experiences of hh education within the last year, hh campaigns, hh monitoring and feedback, and mass media information. yes/no answers were coded as 'yes'=1, 'no'=0. data were analysed using spss version 24.0 (ibm corp., armonk, ny, usa), and alpha values <0.05 were considered to indicate statistical significance. the cronbach alpha was calculated to determine reliability. descriptive statistics were calculated. descriptive data for knowledge, perceptions, attitudes, role models, and self-reported hh performance are presented as mean±standard deviation (sd), minimum, maximum, and median. the per-centage of correct answers to each question in the knowledge domain was scaled as high (90% and over), medium (70-89%), and low (69% and below). this scale was established after the proportion of correct answers of each question was analysed (table s2) ; the mean and sd were calculated as 70.3 and 30.8%, respectively. thus, 70% was assigned as a medium score, and a high score would be recommended to correspond to the mean 1 or 2 sd; however in this study, that figure would be over 100%, so 90% was assigned as the cutoff for a high score. the data were found not to be distributed normally based on the kolmogorov-smirnov test (p<0.001). non-parametric univariate statistical analyses were conducted using the mann-whitney u and kruskal-wallis tests. simple linear regression analysis was conducted to confirm the relationship between the self-reported hh performance of self and that of non-self. pearson correlation analysis was conducted to identify associations among knowledge, perceptions, attitudes, and self-reported hh performance of self. multivariate analysis with multiple linear regression with stepwise variable selection was conducted using variables that were confirmed to be statistically significant in the univariate analysis and correlation analysis. the cronbach alpha values were 0.611 (domain a, knowledge), 0.932 (domain b, perceptions), 0.774 (domain c, attitudes) and 0.900 (domain c, role models) in this study. these values were 0.381, 0.532, 0.576, and 0.932, respectively, in the pilot study. the study was approved by the institutional review board of sunchon national university (104173-201705-hr-013-02, 104173-201709-hr-023-02). prior to participating, written informed consent was obtained from each participant; participants were also informed that their consent could be withdrawn at any time during the study. in the 5 hospitals included in this study, there were 319.0± 223.5 beds (mean±sd) and 441.9±383.7 (mean±sd) hcws, 3 had an icd and 4 had an icn (1 had a part-time icn, 3 had full-time icns), and 2 were general hospitals. the demographics and general characteristics of the participants are presented in table 1 . participants' mean±sd score of knowledge was 17.6±2.5; the proportion of high and medium levels of correct answers for knowledge was 68.0% (table 2) . some questions showed a low proportion of correct answers, as follows (table s1 ): "a3: what is the most frequent source of germs responsible for health care-associated infections?" (40.8%); "a4-2: hand rubbing causes skin dryness more than hand washing" (27.7%); "a7-3: after exposure to the immediate surroundings of a patient" (10.0%); "a8-4: after exposure to the immediate surroundings of a patient" (11.4%); "a10-4: regular use of a hand cream" (0.7%). participants' mean±sd perception score was 69.3±0.8 (table s2). the following questions about perceptions showed low mean±sd scores: "b6.3: hh posters are displayed at points of care as reminders" (6.2±1.0), "b7: what importance does the head of your department attach to the fact that you perform optimal hh?" (6.2±1.0), "b8: what importance do your colleagues attach to the fact that you perform optimal hh?" (6.2±1.0), and "b9: what importance do patients attach to the fact that you perform optimal hh?" (6.2±1.0). the self-reported hai rate (%) was identified as 33.2±27.8 (mean±sd). the self-reported hh performance of non-self (other hcws) was 86.0±11.0 (mean±sd). the self-reported hh performance of self was 88.2±11.0 (mean±sd); this was highest after body fluid exposure/risk (96.2±9.6) and lowest before touching a patient (81.3±17.6). participants' mean±sd scores in the attitudes and role models of c domains were 50.5±5.5 and 46.9±3.3 (table s2) . some questions on attitudes showed extraordinarily low mean±sd scores. in particular, the scores of "c7: hh is convenient." and "c8: hh is protective" were 5.9±1.3, and 5.2±1.9, respectively. some questions on role models showed low mean±sd scores, as follows (table s2) : "cr1: i think that the charge nurse is performing according to the hospital's regulations" and "cr6: i think that my colleague nurses are performing hh according to the hospital's regulations" both received a score of 6.6±0.6. the mean knowledge scores were significantly higher among participants who had received hh education within the past year; those who worked at a hospital with an icd, icn, or hh campaign, or where hh performance was monitored; those who worked in general hospitals; and those whose hospitals employed a full-time icn (compared with those with no icn or a part-time icn) ( table 3) . the mean perceptions scores were significantly higher among participants whose hh performance was monitored; those who monitored their colleagues' hh performance; those who had experienced hh campaigns; those who were married; those who had higher education levels; and those who had higher positions ( table 3 ). the mean scores for self-reported hh performance of self were significantly higher among hcws who had received hh education within the past year; those whose hh performance was monitored; those who monitored their colleagues' hh performance; and those who had higher positions (table 3) . no independent variables were associated with significant differences in the scores for attitudes or role models in the univariate analyses. the correlation analysis among knowledge, perceptions, attitudes, and self-reported hh performance of self identified significant positive correlations among all categories except knowledge (table 4 ). the model for the self-reported hh performance rates of self and non-self was follows. the hh performance rate of non-self was calculated as y1 =36.678+0.555x1 (hh performance rate of self), and a significant linear relationship was found (adjusted r 2 =0.280, p<0.001) ( table 5 ). the regression model for knowledge was calculated as y2 =16.956+0.486x21 (receiving education within the past year)+0.682x22 (icd)+0.451x23 (icn) -0.558x24 (type of hospital). the coefficient of each predictor was not statistically significant, but the model as a whole did show statistical significance (adjusted r 2 =0.055, p<0.001) ( table 5 ). the regression model for perceptions was calculated as y3 =61.408+2.566x31 (hh performance was monitored)+ 1.054x32 (monitoring colleagues' hh performance)+1.611x33 (hh campaign)+0.850x34 (marital status)+0.871x35 (education level)+0.978x36 (position). the coefficients were not statistically significant, but the model as a whole did show statistical significance (adjusted r 2 =0.078, p<0.001) ( table 5 ). the regression model for self-reported hh performance of self was not calculated by multiple linear regression using the variables found to be significant in the univariate analysis. the regression model for performance was calculated as y4 =18.302+0.247x41 (perceptions)+0.232x42 (attitudes)+ 0.875x42 (role model); the coefficients were statistically signifi in terms of infection control infrastructure [16] , icds and icns were not fully allocated across the hospitals analysed in this study. the values for numbers of sinks and the placement of alcohol-based hand rub stations in this study were no worse than has been reported in previous studies (in 2014) of large korean hospitals [17] . however, as resources for hh, the placement of sinks in every room and alcohol-based hand rub stations by every bed, as well as supplying alcohol-based hand rub to every hcw should be improved continuously. in terms of hh activities, most participants (94.5%) had received hh education; however, the scores for other activities such as hh campaign experience and hh monitoring activities were low. these issues can be easily resolved with icd and icn placement [16, 18] . such improvements should be made continuously until the korean health care quality standards are satisfied [19] . the mean score of knowledge among our participants (17.6±2.5) was higher than was reported in previous studies (8.1±1.4 [8] , 14.2±2.0 [10] , and 14.2±2.6 [20] ) conducted by the same method (who questionnaire). however, the proportion of medium and high levels of correct answers was 68.0%. moreover, serious weaknesses in knowledge were found in response to the following questions: "what is the most frequent source of germs responsible for health care-associated infections?", "hand rubbing causes skin dryness more than hand washing", "a7-3: after exposure to the immediate surroundings of a patient", "a8-4: after exposure to the immediate surroundings of a patient", and "regular use of a hand cream". therefore, hh education programs should be promptly reviewed, and systemic and advanced hh education and training programs must be developed and implemented to enhance hh knowledge broadly, not just focusing on these specific knowledge questions. the perceptions in this study (69.3±0.8; total score, 77) were somewhat higher than observed in a previous study (75.2± 11.8; total score, 96) [10] . however, some perceptions-related items that received low scores should be improved, because perceptions have been shown to be significant predictors of nurses' hh intentions and adherence [21] , and an important predictor of hh performance [13, 22] . self-reported hh performance of self was highest after body fluid exposure/risk and lowest before touching a patient. this finding corresponds to those of previous observational studies [9, 23] and is consistent with a previous self-reported performance study [24] . interestingly, the relationship between the hh performance of self and that of non-self was positive and linear. this finding is also consistent with a previous report [25] . participants evaluated the hh performance of non-self at 0.555 times the hh performance of self. attitudes about hh were relatively poor in responses to both "hh is convenient" and "hh is protective". these findings may represent barriers to maintaining good hh, and also demonstrate the need for strategies to promote the perceived convenience and protectiveness of hh [1] . in the role model domain, "it is important for my colleagues to perform hh according to the hospital's regulations" showed high endorsement, and nursing colleagues were identified as the most important hh role models. these results are consistent with previous studies [11] [12] [13] 21, 26] . moreover, the perception of being a role model for one's colleagues can be used to improve hh compliance [13, 25] . according to the multiple linear regression analysis, receiving education within the past year (yes), having an icd (yes), and having an icn (yes) positively affected knowledge, while type of hospitals negatively affected knowledge. hh performance being monitored (yes), monitoring colleagues' hh performance (yes), and the presence of an hh campaign (yes) positively affected perceptions. therefore, these findings can be used to improve knowledge and perceptions. as this study was not an observational study of hh performance, this study has some limitations in terms of the self-reporting of hh performance. the regression model of self-reported hh performance of self showed increases with 0.247 (perceptions)+0.232 (attitudes)+0.875 (role models). knowledge was excluded from this model. consistently with previous studies [13, 21, 22, 25] , our participants' self-reported hh performance rate of self was positively correlated with their scores for perceptions, attitudes, and role models. an explanation for this is that general perceptions of hh [13, 21, 22] and the perception of being a role model for one's colleagues [13, 25] are very important for improving hh compliance among hcws [13] . as such, these findings could be used in future hh promotion strategies for nurses. in this study, the hh knowledge, perceptions, attitudes, and role models of rns in community-based hospitals in a small-to-medium urban area were characterized. the presence of some items with relatively low scores revealed some room for improvements in knowledge. receiving education within the past year, having an icd, and having an icn were found to be related to knowledge. in addition, hh campaigns and monitoring were associated with perceptions. the self-reported hh performance rate of self was associated with perceptions, attitudes, and role models. world health organization. who guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care office of disease prevention and health promotion evidence-based model for hand transmission during patient care and the role of improved practices point of care hand hygiene-where's the rub? a survey of us and canadian health care workers' knowledge, attitudes, and practices mers outbreak in korea: hospital-to-hospital transmission middle east respiratory syndrome coronavirus (mers-cov) outbreak in south korea, 2015: epidemiology, characteristics and public health implications national survey of the status of infection surveillance and control programs in acute care hospitals with more than 300 beds in the republic of korea knowledge and beliefs about hand hygiene among hospital nurses hand hygiene compliance of healthcare workers in a children's hospital p161: knowledge and perception toward hand hygiene among health-care workers in teaching hospital perceptions, attitudes, and behavior towards patient hand hygiene key beliefs of hospital nurses' hand-hygiene behaviour: protecting your peers and needing effective reminders improved hand hygiene compliance is associated with the change of perception toward hand hygiene among medical personnel world health organization. hand hygiene knowledge questionnaire for health-care workers world health organization. perception survey for health-care workers study on the efficacy of nosocomial infection control (senic project): results and implications for the future the status of healthcare-associated infection control among healthcare facilities in korea development and application of evaluation indices for hospital infection surveillance and control programs in the republic of korea reference material knowledge, attitudes, and practices study on hand hygiene among imam hossein hospital's residents in 2013 understanding the determinants of australian hospital nurses' hand hygiene decisions following the implementation of a national hand hygiene initiative nurses and physicians' perceptions of the importance and impact of healthcare-associated infections and hand hygiene: a multi-center exploratory study in hong kong analysis of hand hygiene practices of health care personnels understanding healthcare workers self-reported practices, knowledge and attitude about hand hygiene in a medical setting in rural india importance of structured training programs and good role models in hand hygiene in developing countries nurses' knowledge regarding hand hygiene and its individual and organizational predictors this research was supported by sunchon national university funds (2017). the author has no conflicts of interest associated with the material presented in this paper. key: cord-013336-42thiglv authors: wang, cheng; wang, ya-jie; tucker, joseph d.; xiong, ming-zhou; fu, hong-yun; smith, m. kumi; tang, wei-ming; ong, jason j.; zheng, he-ping; yang, bin title: correlates of hiv self-testing among female sex workers in china: implications for expanding hiv screening date: 2020-10-22 journal: infect dis poverty doi: 10.1186/s40249-020-00765-5 sha: doc_id: 13336 cord_uid: 42thiglv background: human immunodeficiency virus (hiv) self-testing may help improve test uptake among female sex workers. china has implemented many hiv self-testing programs among men who have sex with men, creating an opportunity for promotion among female sex workers. however, there is a limited literature on examining hiv self-testing among female sex workers. this study aimed to examine hiv self-testing experiences and its determinants among female sex workers in china. methods: a venue-based, cross-sectional study was conducted among chinese female sex workers in 2019. participants completed a survey including social-demographic characteristics, sexual behaviors, and hiv self-testing history, the distribution of which were analyzed using descriptive analysis. multivariable logistic regression was conducted to identify associations with hiv self-testing. results: among 1287 chinese female sex workers, 1072 (83.3%, 95% confidence interval [ci] 81.2–85.3%) had ever tested for hiv, and 103 (8.0%, 95% ci 6.6–9.6%) had ever used hiv self-testing. more than half reported that the self-test was their first hiv test (59.2%, 61/103), around one-fifth reported hiv self-testing results influenced the price of sex (21.4%, 22/103). a minority of individuals reported ever experiencing pressure to undertake hiv self-testing (6.8%, 7/103). after adjusting for covariates, hiv self-testing was positively associated with receiving anal sex in the past month (adjusted odds ratio [aor] = 2.2, 95% ci 1.4–3.5), using drugs before or during sex (aor = 2.8, 95% ci 1.8–4.5), injecting drugs in the past 6 months (aor = 2.6, 95% ci 1.2–6.0), being diagnosed with other sexually transmitted infections (aor = 1.6, 95% ci 1.0–2.5), tested for other sexually transmitted infections in the past six months (aor = 3.4, 95% ci 2.1–5.5), ever tested in the hospital (aor = 3.4, 95% ci 2.0–5.6), and ever tested in the community (aor = 1.5, 95% ci 1.2–1.9). conclusions: our findings suggest that hiv self-testing could expand overall hiv testing uptake, increase hiv testing frequency, reach sub-groups of high-risk female sex workers and has limited potential harms among female sex workers. hiv self-testing should be incorporated among chinese female sex workers as a complement to facility-based hiv testing services. (sti) acquisition [2] . the world health organization recommends frequent hiv testing in female sex workers to increase engagement in hiv prevention services and reduce risk of onward transmission [3] . however, hiv testing uptake remains low among female sex workers in low-and middle-income countries (lmic) [4, 5] . in china, studies suggest that approximately half of female sex workers remain unaware of their hiv serostatus [6, 7] . although facility-based hiv testing have helped increase testing coverage among female sex workers in china [7, 8] , many barriers persist. these include concerns about confidentiality of status [9] , lack of privacy [7] , fear of social stigma and condemnation [10] , lack of health care providers and inconvenient testing systems [11] . self-testing for hiv may help improve test uptake among female sex workers. self-testing is the process whereby a person collects a specimen, performs the test, and interprets the result themselves. studies in female sex workers in uganda [12] , kenya [13] , malawi [14] , and zambia [15] have shown that hiv self-testing can increase the frequency of hiv testing and safer sex practices, decrease stigma associated with hiv testing, provide a user-friendly, rapid, accurate and private setting of testing, as well as an opportunity for decentralized hiv testing and alternative service delivery models. however, there have been few studies examining hiv self-testing among female sex workers in countries outside of sub-saharan africa, including china [16] [17] [18] . currently, a total of 59 countries globally have policies supporting using hiv self-testing among key populations [19] . in china, highly sensitive and specific hiv self-test kits are available through community-based organizations or e-commerce platforms [11] . china has implemented many hiv self-testing programs and gained experience among men who have sex with men (msm) [20, 21] , creating an opportunity to promote hiv self-testing among female sex workers. the aim of this study was to examine hiv self-testing experiences and its determinants among female sex workers in china. a venue-based, cross-sectional study was conducted in eight cities (beijing, tianjin, shenzhen, kunming, jiaozhou, yunfu, xiangyang and longnan) within seven provinces in china between august 17 and october 17, 2019. these eight cities were selected based on local capacity and the availability of ongoing public health outreach programs for female sex workers. we partnered with eight local female sex workers community-based organizations (cbo) in those eight cities with experience of conducting female sex workers outreach programs including condom promotion, sexual health education, hiv and syphilis rapid testing and counseling, and linkage to care (accompaniment to clinical services for infected individuals). prior to this study, a mapping of the sex work venues was performed by local cbo in each study site according to geographic area and type of venue. a convenience sampling method was used to recruit female sex workers in selected venues in each city. we categorized the sex work venues into high tier and low tier based on the clientele's socioeconomic status [22] . low tier venues include foot bathing shops, hair salons or barber shops, massage parlors, roadside restaurants, roadside shops, guesthouses, streets or public outdoor places. high tier venues include karaoke bars, hotels, sauna, and nightclub. at each site, at least 30% of participants were lowtier sex workers. the inclusion criteria for this study were as follows: born biologically as a female; aged 18 or above; exchanged sex at least once for money/goods in the past three months; willing to participate and complete the survey. the survey questionnaire was created on wenjuanxing (changsha haoxing information technology co., ltd., changsha, china) based on discussions with local cbo stakeholders, policy makers and international hiv experts. we also piloted the survey with 50 volunteer female sex workers. the purpose of this formative research was to ensure the survey was simple to complete and consistent with our written survey content. this pilot data was not included in the final analysis. in the formal survey, each questionnaire was selfadministered by eligible participants with the help of outreach workers. participants would receive united states dollars (usd) 2 on completion of the study. the questionnaires submitted within five minutes were deemed invalid based on our pilot testing prior to the study that a minimum time of five minutes were required to respond all the survey items. social-demographic and sexual behavior characteristics included: age, marital status, place of residence, annual income, education, time of providing commercial sex in the current location, number of cities worked for selling sex, number of clients served in the past month, charge for vaginal sex, whether condoms were used consistently when engaged in commercial sex in the past month, illicit substance use, sti testing history. consistent condom use in the past month was defined as always using a condom during commercial sex. self-testing history for hiv included location where the kit was obtained, self-test results, post-test healthcare seeking behaviors, change in testing frequency after the first use of a self-test kit, experienced pressure from selftesting, whether giving or selling a self-test kit to a client, influences of performing self-testing on sex exchange. categories of pressure included physical violence, threats of violence, verbal abuse, psychological pressure, excessive control of activities, withholding of household resources, and threats to end a relationship [23] . descriptive analysis was conducted to describe the distribution of the sample regarding background characteristics, substance use, sexual behaviors, hiv and syphilis testing. univariable and multivariable logistic regression was conducted to explore socio-demographic and behavioral variables associated with hiv self-testing. in the multivariable model we adjusted for age, legal marital status, educational attainment, and annual income. all analyses were conducted on sas (v9.2, sas institute inc., cary, nc). this study was approved by the dermatology hospital of southern medical university (2019017). a verbal informed consent was obtained from all the participants who agreed to participate in this study. overall, 1443 women met the inclusion criteria. eightyone individuals declined to participant the study, and 77 completed the questionnaire less than five minutes. finally, a total number of 1287 women completed the survey. among those participants, 1072 (83.3%) had ever tested for hiv, and 103 (8.0%) had ever used hiv self-testing. most participants were between 18 and 35 years old (53.8%), from low tier venues (57.3%), married (43.8%), had a junior high school degree (45.2%), and had an annual income between usd 5001 and usd 14 000 (56.3%). the majority were employed (54.4%), residing in the province where the study was done (51.4%) and working in current location over one year (50.51%). the socio-demographic characteristics of respondents who ever used hiv self-testing were comparable to women who never used hiv self-testing (table 1) . of 1287 individuals, the median number of clients served in the past month was 22 (interquartile range [iqr]: 12-56). the median amount of payment received for vaginal sex was usd 20 (iqr: 15-45). and 42.1% (542/1287) reported using condoms consistently when engaged in commercial vaginal sex in the past month. for oral sex, 58.3% (750/1287) reported providing oral sex in the past month, of whom only 16% (120/750) reported using condom consistently. for anal sex, 18.9% (243/1287) reported receiving anal sex in the past month and 41.6% (101/243) reported using condom consistently. the vast majority of women (78.4%, 1009/1287) reported having never used drugs before or during sex. almost three-fifth of women (59.7%, 768/1287) reported bulk purchasing of condoms, and a small proportion of individuals (5.2%, 67/1287) have experience of bulk purchasing hiv self-testing kits ( table 2) . 9%, 3/103 ). the majority sought care following reactive/indeterminate hiv self-testing result (81.8%, 9/11). among those individuals who sought care after hiv self-testing, most women sought care within two weeks (66.7%, 6/9), and either at a specialty sexually transmitted infection (sti) clinic or in a health facility run by the centers for disease control (table 3) . among individuals who had hiv self-tested, around one-fifth reported hiv self-testing results influenced the price of sex (21.4%, 22/103). a minority of individuals reported ever experiencing pressure to undertake hiv self-testing (6.8%, 7/103). the most common pressure was psychological pressure (2.9%, 3/103), followed by threatened to end a relationship (2.9%, 3/103) ( table 3) . a majority of hiv self-testers reported some difficulties in performing hiv self-testing (71.84%, 74/103). pricking fingers (59.5%, 44/74) or using collection tube to collect blood (50.0%, 37/74) were the most commonly reported difficulty. the most commonly reported reasons for using hiv self-testing were that they wanted to know their infection status (55.3%, 57/103), and they recently had high risk contact (54.4%, 56/103). the most common reason for not performing self-testing was that they had never heard of hiv self-testing before (42.6%, 504/1184) (additional file 1: table s1 ). in the multivariable model adjusted for age, legal marital status, educational attainment and annual income, the following factors were positively correlated with hiv self-testing: receiving anal sex in the past month (adjusted odds ratio [aor] = 2.2, 95% ci 1.4-3.5), using drug before or during sex (aor = 2.8, 95% ci 1. 8-4.5) , injecting drugs in the past six months (aor = 2.6, 95% ci 1.2-6.0), being diagnosed with other stis (aor = 1.6, 95% ci 1.0-2.5), tested for other stis in the past 6 months (aor = 3.4, 95% ci 2.1-5.5), ever tested in the hospital (aor = 3.4, 95% ci 2.0-5.6), and ever tested in the community (aor = 1.5, 95% ci 1.2-1.9) ( table 4 ). female sex workers are at high risk of hiv acquisition and transmission [24] . our study suggests that self-testing for hiv could expand overall testing uptake, increase testing frequency, and has limited potential harms among female sex workers. this study expands the literature by focusing on hiv self-testing among female sex workers, including women from multiple provinces, and exploring associated benefits and harms. findings from this study can help inform hiv self-testing interventions among female sex workers. our study suggests that few female sex workers in china have performed hiv self-testing. this is consistent with rates of hiv self-testing reported in malawi [14] , zimbabwe [15] , uganda [12] , and kenya [13] . since the world health organization released guidelines recommending hiv self-testing among under-served and high-risk populations in 2016 [25] , many studies in the sub-saharan africa have shown that hiv self-testing has a good acceptability and feasibility for female sex workers [12, 14, 15, 26] . studies have suggested that adding hiv self-testing to existing community-based testing and counseling services among female sex workers is acceptable, cost-effective and efficient to improve linkage to care [15, 26, 27] . china should take more effort to explore strategies integrating hiv self-testing to existing facility-based testing services. additionally, in the context of wide online availability of hiv self-testing kits in china [11] , our data could help to inform interventions. our study found low frequency of physical violence or other types of violence related to hiv self-testing among female sex workers. the frequency of physical violence associated with hiv self-testing is comparable to that reported in zambia [15] and kenya [13] . intimate partner violence is common and could be exacerbated by self-testing services that inadvertently allow a sex worker manager or partner to influence testing behaviors [13, 28] . our results suggest that self-testing is not associated with physical violence, although further research and attention are needed. we found that self-testing for hiv can effectively reach high-risk female sex workers, and facilitate higher frequency testing. in our study, hiv self-testing was correlated with receiving commercial anal sex in the past month and drug use before or during sex. this finding is consistent with studies conducted among men who have sex with men in china [21] and france [29] . additionally, our study found that a large proportion of hiv selftesters reported having never been tested for hiv before the self-testing, and approximately one-third of hiv selftesters reported increasing testing uptake after initial use of hiv self-testing. this suggests hiv self-testing has the potential to increase the frequency of hiv testing among female sex workers, specifically among individuals not reached by provider-based strategies [11, 30] . our study has several limitations. first, the survey captured a convenience sample of female sex workers population in china, likely resulting in selection bias. although the convenience sampling method can generally be implemented more easily, faster and with fewer resources [31] , the study sample might not be representative of the population as a whole, which limits the statistical inference and generalizations [32] . second, this study was conducted among female sex workers in cities with relatively high involvement in hiv prevention programs. the results of this study may not be generalizable to female sex workers in cities that have fewer hiv prevention programs. third, all the data were collected through self-report, which may be prone to information bias. although self-testing for hiv may be effective in expanding female sex workers testing uptake and frequency, several challenges remain. individuals with a reactive result require a clinic visit for confirmation of infection, which can be inconvenient, and create a barrier for female sex workers to linkage to care [33] . female sex workers tend to be high degree of mobility and vulnerable to criminality [34] , highlighting the need of social support for training, counseling, and ancillary self-testing services [15] . adequate linkages to counseling, treatment, and care for hiv self-testers who test positive, and test quality assurance remain essential [35] . innovative approaches are needed to improve hiv testing uptake among female sex workers. our findings suggest that hiv self-testing has the potential to expand overall testing uptake, enable more frequent testing, reach sub-groups of high-risk female sex workers, and has limited potential harms among female sex workers. self-testing for hiv should be incorporated among chinese female sex workers as a complement to facilitybased testing services. future studies to explore effective mode of promoting hiv self-testing among female sex workers are warranted. supplementary information accompanies this paper at https ://doi. org/10.1186/s4024 9-020-00765 -5. additional file 1: table s1 . difficulties and reasons for performing hiv self-testing among chinese female sex workers. hiv: human immunodeficiency virus; sti: sexually transmitted infections; lmic: low-and middle-income countries; ci: confidence interval; cor: crude odd ratio; aor: adjusted odd ratio; iqr: interquartile range. unaids report on the global aids epidemic need for intervention services for promotion of condom use by female sex workers to consider size of entertainment venues: a cross-sectional study world health organization. consolidated guidelines on hiv testing. geneva: world health organization africans in south china face social and health barriers joint united nations programme on hiv/aids; 2016 the hiv, syphilis, and hcv epidemics among female sex workers in china: results from a serial cross-sectional study between the neglected health of international migrant workers in the covid-19 epidemic analysis of situation and influencing factors of providing hiv rapid testing service by community based organizations expanding syphilis testing: a scoping review of syphilis testing interventions among key populations 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 incarcerated sex workers and hiv prevention in china: social suffering and social justice countermeasures syphilis self-testing: a nationwide pragmatic study among men who have sex with men in china direct provision versus facility collection of hiv self-tests among female sex workers in uganda: a cluster-randomized controlled health systems trial promoting male partner hiv testing and safer sexual decision making through secondary distribution of self-tests by hiv-negative female sex workers and women receiving antenatal and post-partum care in kenya: a cohort study hiv self-testing services for female sex workers, malawi and zimbabwe hiv self-testing among female sex workers in zambia: a cluster randomized controlled trial attitudes and acceptability on hiv self-testing among key populations: a literature review scaling up hiv self-testing in sub-saharan africa: a review of technology, policy and evidence hiv self-testing in pune, india: perspectives and recommendations of female sex workers and peer educators global output of research on the health of international migrant workers from acceptability and feasibility of a social entrepreneurship testing model to promote hiv self-testing and linkage to care among men who have sex with men hiv self-testing among online msm in china: implications for expanding hiv testing among key populations the prevalences of neisseria gonorrhoeae and chlamydia trachomatis infections among female sex workers in china pressured hiv testing "in the name of love": a mixed methods analysis of pressured hiv testing among men who have sex with men in china hiv infection among female sex workers in concentrated and high prevalence epidemics: why a structural determinants framework is needed world health organization. guidelines on hiv self-testing and partner notification: supplement to consolidated guidelines on hiv testing services. geneva: world health organization cost-effectiveness of community-based human immunodeficiency virus self-testing in the impact and cost-effectiveness of community-based hiv self-testing in sub-saharan africa: a health economic and modelling analysis acceptability of woman-delivered hiv self-testing to the male partner, and additional interventions: a qualitative study of antenatal care participants in malawi access to and use of unauthorised online hiv self-tests by internet-using french-speaking men who have sex with men usage of purchased self-tests for hiv and sexually transmitted infections in amsterdam, the netherlands: results of populationbased and serial cross-sectional studies among the general population and sexual risk groups a comparison of respondent-driven and venue-based sampling of female sex workers in liuzhou sampling studies to estimate the hiv prevalence rate in female commercial sex workers hiv testing in a high-incidence population: is antibody testing alone good enough? addressing vulnerabilities of female sex workers in an hiv prevention intervention in mumbai and thane: experiences from the aastha project a review of self-testing for hiv: research and policy priorities in a new era of hiv prevention publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we are very grateful to all the participants who participated in this study. authors' contributions cw, mx and by developed the initial concept for the manuscript. cw drafted an initial draft. yw conducted the statistical analysis. the remaining authors (jdt, hf, wt, mks, jjo, hz) edited and contributed content to the final draft. all authors have read and approved the final manuscript. all authors read and approved the final manuscript. this work was supported by guangdong medical research foundation (a2019402). the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. not applicable. not applicable. the authors declare no conflicts of interest. key: cord-265937-f39md0vk authors: cachón-zagalaz, javier; sanabrias-moreno, déborah; sánchez-zafra, maría; zagalaz-sánchez, maría luisa; lara-sánchez, amador jesús title: use of the smartphone and self-concept in university students according to the gender variable date: 2020-06-12 journal: int j environ res public health doi: 10.3390/ijerph17124184 sha: doc_id: 265937 cord_uid: f39md0vk the university stage comprises a very important and vital period in the modification of students’ lifestyles, and these changes can affect their self-concept. the excessive use of technology today can also influence the formation of their identity. the aim of this study is to analyze the relationship between self-concept and the use of the smartphone by university students in terms of gender. the sample included 253 students (mean age 21.39 ± 3.27) of the primary education degree of the university of jaén (106 men and 147 women). a questionnaire was used to unify several instruments: a sociodemographic questionnaire, a self-concept form-5 questionnaire (af-5), and a questionnaire on cell phone-related experiences (cerm). the results show the existence of significant differences between both genders in the academic, emotional, and social dimensions of self-concept, with women showing a greater academic self-concept and men showing an emotional and physical one. regarding the use of the smartphone in relation to self-concept, significant differences are found in the academic and emotional dimensions depending on the degree of use. in addition, in relation to the use of the smartphone, it has been detected that half of the students present potential problems. it is concluded that there is a relationship between both constructs, especially the academic and emotional self-concept. the university stage coincides with what some authors describe as emerging adulthood, a period of life in which people between the ages of 18 and 29 have passed through adolescence but have not yet fully assumed the role of an adult [1] [2] [3] [4] [5] [6] . this cycle also coincides with a total change in lifestyle, since it involves interaction with a new group of people, the abandonment of the family nucleus in many cases, and the possible combination of studies and work. it is a time that can cause certain instability, since it is the moment when the subject strengthens his personality [7] . related to these cognitive and psychological processes arises the term self-concept, a construct of high importance in this stage of change and consolidation of personal identity which is defined as the perception that an individual has of himself, taking into account limitations, characteristics, and personal relationships [8] [9] [10] . this self-perception is flexible and modifiable-that is, it is not the same throughout an individual's life and is influenced by all the changes that the subject experiences in the different areas of his or her day-to-day life and furthermore, is influenced by the reinforcements, positive or negative, that other people exert on the individual [11] . some authors argue that there are differences in some dimensions of self-concept according to gender, as indicated, for example, in the study by cachón et al. (2015) [8] . the concept has also undergone several changes in its definition over the last few decades. in the seventies of the last century, the self-concept had a one-dimensional character-it was a single factor. in this line, the rosenberg self-esteem scale [12] , which measured this single dimension, became popular. over the years, the deepening of the study of this construct led the scientific community to consider its multidimensional nature. in this sense, the study by shavelson et al. (1976) [13] already defined self-concept as a hierarchical model formed by several factors or dimensions, so that a person can have a high self-concept in several aspects of his life and a low one in others. currently, the model that divides the self-concept into five dimensions is formally accepted: physical, related to body image and physical factors; emotional, understood as the ability to manage emotions that the individual has; family and perception about the role within the family; academic, in his role as a student; and social, conditioned by the quantity and quality of social relationships [14] [15] [16] [17] . the self-concept form-5 questionnaire by garcía and musitu (1999) [18] is the most widely used in this regard. on the other hand, it cannot be ignored that today's society is technological and constantly changing. technological advances have a great impact on people's lives, on the activities they carry out, and on their socialization [19] . mobile phones or smartphones (terms that will be used interchangeably in this paper) are currently one of the most famous products, are within the reach of almost all subjects, and are part of their lives. the use of these devices has become widespread, and it is common to manipulate them at any time of day, walking on the street, on public transport, at home, or even in class or at work. according to the ditrendia report [20] , which analyses various aspects of mobile phone use, there were more than five billion users in 2019. in the specific case of spain, 96% of the population uses them to access the internet. in 2018, it has been estimated that users worldwide spent an average of 800 h using their smartphones to surf the internet, and this figure is expected to increase to 930 h in 2021. the covid-19 pandemic has broken these forecasts, with mobile phone use skyrocketing in 2020 during periods of confinement. for example, in spain during the second week of march and coinciding with the beginning of the state of alarm, mobile phone use increased by 38.3% compared to the last week of february. in general, the use of communication applications has increased by more than 50%, social networks by 20.9%, and television and cinema by a similar percentage. among the most used applications in the communication sector are "hangouts"; "whatsapp"; and "calls", especially video calls, while in the social network sector are "twitter", "facebook", and "instagram". the television and film applications that have increased their use the most are "megadede", "netflix", and "prime video" [21] . returning to the use of mobile phones, 85% of spanish users use messaging applications, with whatsapp being the most widely used, especially among young people between 14 and 24 years old. the second most applied activity by the spanish is related to the display of videos (82%), and the third is the display of mobile mapping programs (75%). the favorite applications are games, social networks, entertainment, and photography [20] . as we have maintained, the smartphone is now a must-have for many people. throughout the history of mankind, there are few elements that have been so influential in the lives of human beings, so the problem of dependence that it manages to create in its users is generated, and this can even affect relationships with other people. it is at this point that we talk about social problems related to the use of mobile phones [22] , which are complemented by others that are also derived from this excessive use, such as lack of sleep, loss of the notion of time, obsession with what is happening on social networks, or the failure to do other important activities. despite the fact that this device is used by both genders, some authors report that women spend the most time using it [23] . the use of the smartphone is especially noticeable among young people. the group of university students, along with teenagers, is one of the most likely to suffer from addiction problems, since the mobile phone is a first and indispensable object for them, and they consider it a fundamental tool to relate to and socialize with others [24] . the media is an essential tool for young people, but at this age its use is dangerous as it can influence people and change their behavior without them being aware [25] . the excessive use of the smartphone can cause health problems affecting sleep, increase the risk of having a traffic accident or influence academic results. in relation to this term, the concept of "phubbing" arises, understood as the fact of neglecting other people by continuously using the smartphone [26] . it should be noted that the two main constructs of this research (self-concept and the use of the smartphone) can influence each other, since one of the transcendental uses that young people give to the mobile phone is access to social networks in which they continually interact by publishing photographs with the intention of showing a lifestyle, real or imaginary. this digital individual is changeable and usually responds to the desires of the real subject, to how he wants to be seen or how he wants to see himself. it is essential to educate students about the dangers that can be caused by social networks, reminding them that the information they see published is usually subject to filters that transmit unreal information or with a very biased truth [27] however, this process may not always be negative; the problem arises when the real self is lost and an identity crisis appears, influencing its self-concept [28] . especially in the adolescent stage, it is very important to acquire and maintain a good body image, since this is directly related to the person's general health [29] . likewise, studies such as pedrero et al. (2012) [30] state that the excessive use of mobile phones can make it even more difficult for people with a low self-concept to socialize openly and directly or even to speak of depressive symptoms. some people with low self-esteem and self-concept have trouble interacting with other subjects face-to-face, causing them to prefer to communicate with others through the smartphone, which makes them feel more confident. therefore, people with this low self-concept may have an excessive use of the smartphone [31] . twenge et al. (2018) [32] also comment that teenagers who spend less time using technological devices are happier than those who use them continuously. based on the information found, the hypothesis is that mobile phone use directly affects the self-concept of university students. therefore, the main objective of this study is to analyze the relationship between the self-concept of university students and the use they make of their mobile phones, also analyzing the gender variable. the sample is made up of 253 university students (n = 253) of the primary education degree of the university of jaén (spain). a non-probabilistic sampling of accidental or casual type has been used. the distribution of participants according to gender is as follows: 106 men (41.9%) and 147 women (58.1%). the mean age of the sample subjects is 21.39 (±3.27); the minimum age of the participants is 18 and the maximum is 42 (range = 24 years). (4, 9, 14, 19, 24 and 29) , and physical (5, 10, 15, 20, 25 and 30) . an example of an item is: "it's difficult for me to make friends". the type of response is a likert scale of between 1 and 5 points, with 1 being "never" and 5 being "always". in the participants of the study, the initial reliability (including all items) of the scores obtained (cronbach's alpha) was 0.64 for the total of the scale, for the academic dimension 0.81, for the social dimension 0.79, for the emotional dimension 0.65, for the family dimension 0.86, and for the physical dimension 0.78. in the study, item number 8, or "many things make me nervous", has been eliminated because it interfered with the reliability of the scale. excluding this item from the analyses, the total reliability of the scale was 0.87. -questionnaire on cell phone-related experiences (cerm-cuestionario de experiencias relacionadas con el móvil), by beranuy et al. (2009) [33] : scale made up of 10 items answered on a four-point likert scale, with 1 being "almost never" and 4 being "almost always". an example of an item is "do you get angry or irritated when someone bothers you while using your mobile phone?". following authors such as carbonell et al. (2012) [34] , the results have been analyzed by grouping the participants into three groups: "no problems" (10 to 15 points), "occasional problems" (16 to 23 points), and "severe problems" (24 to 40 points). the reliability of the scale (cronbach's alpha) was 0.75. firstly, a questionnaire was developed by linking the above instruments and applying them collectively and voluntarily to participants in their classrooms. at the beginning, they were informed of the nature of the study and were assured of the anonymity of the responses and results. this research also meets the international ethical standards set by the world medical association (wma), which issued the declaration of helsinki in 1964 [35] , although it has undergone subsequent revisions, the latest in 2017. it also complies with the spanish legislation required for this type of work. the spss 22.0 (ibm corps., armonk, ny, usa) statistical program was used for data analysis. a descriptive study was performed to report the characteristics of the sample subjects (means and standard deviations) and various non-parametric tests (spearman's rho correlation, mann-whitney u test, h kruskall wallis), since the assumption of normality was based on the results obtained in the kolmogorov-smirnov test (n > 30) was not met. table 1 shows the results when bivariate correlations are made between the different dimensions of the self-concept, as well as the mean (m) and standard deviation of each one of them. when the u mann-whitney test was performed to relate the dimensions of self-concept with the gender variable (table 2) , statistically significant differences (p < 0.01) were obtained in favor of girls in academic self-concept (z = −3.286, p = 0.001, r = 0.020) and of boys in emotional (z = −5.456, p = 0.000, r = 0.35) and physical self-concepts (z = −5.640, p = 0.000, r = 0.34). in relation to the size of the effect, the values obtained in the variables in which significant differences have been found are of medium size (r < 0.50, r > 0.30). it can be observed that those dimensions with statistically significant differences according to gender have a higher statistical power. as can be seen in table 3 , most university students are classified between those who do not have problems related to mobile phone use (n = 102, 40.3%) and those who may have them (n = 142, 56.1%). only nine students present severe problems (3.6%). in terms of gender differentiation, girls show less problems than boys (n = 59 vs. n = 43), but at the same time they are the ones that show more potential difficulties (n = 84 vs. n = 58). in terms of severe problems, both genders are equal, with the male being slightly superior (n = 5 vs n = 4). table 4 shows the relationship between the dimensions of self-concept and the three categories of mobile phone use. statistically significant differences (p < 0.05) were obtained in the academic dimension (χ 2 = 7.003, p = 0.030, r = 0.027) and in the emotional dimension (χ 2 = 17.351, p = 0.000, r = 0.082), being in both the mean of the category "no problems" the highest (m = 22.38, sd = 3.44 vs. m = 16.47, sd = 2.87). it is observed that the statistical power is higher in those variables in which there are statistically significant differences. sig., significance. * statistically significant differences at the 0.05 level. the results obtained show that of the five dimensions into which the self-concept is divided, the one that scores most is the family one, followed by the social one. these data agree with bustos et al. (2015) [36] and baptista et al. (2012) [14] , for whom the family relationship is a key factor in the lives of people that can affect, positively or negatively, other key aspects of the lives of individuals. this is even more important at the university stage, because most students leave the family nucleus and losing family closeness can affect other aspects of their lives. therefore, it is a very positive fact that the subjects surveyed show high scores in this dimension. with regard to social self-concept, it is important to remember that university students create social bonds with people they meet during their years of study at this institution. a high social self-concept implies, in most cases, that they have no problems in creating new relationships with their peers [37] . the order in which these dimensions are scored continues with the physical and academic dimensions, with the emotional one being the one with the lowest score. logically, the physical self-concept is closely related to physical activity practice, so one way to increase it would be to perform physical exercise regularly [17, 38] . some authors indicate that academic self-concept is influenced by some variables, such as student involvement in the teaching process or the relationship between the teacher and student [9] . it is perhaps for this reason that university students score lower on the academic dimension than on others, given that the relationship between students and teachers at the university is not as close as it is at other educational stages. finally, as for the emotional dimension, which is the one that presents the lowest scores, it has been found that it is closely related to the social one. this is due to the fact that people who consider themselves emotionally strong have more facility when it comes to strengthening ties with other subjects [39] . according to the results, there are statistically significant differences (p < 0.01) between both genders in the academic, emotional, and physical dimensions. women present a higher academic self-concept than men, possibly because they get better grades than men by having better study habits [40] . in contrast to this idea, the article by jiménez-caballero et al. (2015) [41] concludes that gender is not a variable that influences the academic performance of university students. with regard to the emotional and physical dimension, it is men who have higher scores, data which is consistent with chacón-cuberos et al. (2020) [7] . suárez and wilches (2015) [42] claim that men perceive and regulate their emotions better than women. it is important to pay attention to your emotions, because not doing so can lead to some symptoms of depression. in terms of the physical self-concept, linares-manrique et al. (2016) [43] states that men have a superior appreciation of themselves in terms of physical ability, physical condition, strength, and physical attractiveness. as for the use of mobile devices, more than 50% of the sample presents potential problems. it should not be forgotten that most of the university students surveyed belong to what is known as the digital native generation, understood as the people who were born when they switched from the analog to the digital world [19] . in terms of gender differentiation, girls are the group that stands out in the "no problem" category, although they outnumber boys with potential complications related to their use. these results coincide with those of lópez-rosales and jasso-medrano (2019) [23] , who found differences between the time of use of mobile phones between both genders but not addictive behaviors. according to these authors, girls use social networks more frequently to express themselves through them and boys to meet other people. zagalaz et al. (2019) [44] also state that women use their smartphones more, especially to access social networks, and that men prefer to use them to surf the internet or play video games. when analyzing the results obtained in the relationship between the dimensions of self-concept and the use of the smartphone, it is found that there are statistically significant differences (p < 0.05) in the academic and emotional self-concepts, with those subjects who have severe problems with the use of the mobile phone scoring in both dimensions lower. the students are aware that the excessive use of smartphones can reduce their university performance and, as a consequence, their academic self-concept. according to the data obtained by herrera et al. (2014) [45], more than 50% of the young participants in their research stated that they were distracted in class when using their mobile phone. in terms of emotional self-concept, the results are reinforced by olivencia-carrión et al. (2016) [22] , who state that the use of mobile devices can create situations of dependency and emotional attachment, and that they are used to deal with negative emotional situations, such as boredom. finally, as the main conclusion, it should be noted that university students show a high degree of family self-concept, followed by the social and physical self-concepts. the academic and emotional dimensions score the lowest. as for the differentiation by gender, this are found only in the academic self-concept in favor of women and in the emotional and physical dimensions in favor of men. regarding the use of smartphones, more than half of the students surveyed present potential problems related to their use, with a small percentage having severe problems. finally, the relationship between self-concept and mobile phone use is remarkable in the academic and emotional dimensions, being the only ones in which significant differences appear depending on the degree of use of smartphones. 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our smartphones? the vital roles of smartphone activity in smartphone separation anxiety anabolic steroids and their effects on health: a case study of media social responsibility autoconcepto y autoestima en la adolescencia. desarrollo de la identidad personal en las nuevas realidades sociales body image and obesity by stunkard's silhouettes in 14-to 21-year-old italian adolescents adicción o abuso del teléfono móvil. revisión de la literatura how does self-esteem affect mobile phone addiction? the mediating role ofsocial anxiety and interpersonal sensitivity decreases in psychological well-being among american adolescents after 2012 and links to screen time during the rise of smartphone technology validación de dos escalas breves para evaluar la adicción a internet y el abuso de móvil problematic internet and cell phone use in spanish teenagers and young students declaration of helsinki ethical principles for medical research involving human subjects validación del autoconcepto forma 5 en universitarios peruanos: una herramienta para la psicología positiva relaciones sociales y escolares de alumnos universitarios diferencias del autoconcepto físico en practicantes y no practicantes de actividad física en estudiantes universitarios habilidades sociales y autoconcepto en estudiantes universitarios de la región altos sur de jaliso importancia de los hábitos de estudio en el rendimiento académico del adolescente: diferencias por género factores determinantes del rendimiento académico universitario en el espacio europeo de educación superior habilidades emocionales en una muestra de estudiantes universitarios: las diferencias de género the relation of physical self-concept, anxiety, and bmi among mexicam university students acknowledgments: this article has counted with the collaboration of the group hum-653 of the university of jaén. likewise, we would like to thank the students of the university of jaén for their collaboration. the authors declare no conflict of interest. key: cord-029192-yxk040wl authors: halil, yasmin; meyer, gereon title: societal expectations from automated road mobility: results of a survey in germany date: 2020-06-12 journal: road vehicle automation 7 doi: 10.1007/978-3-030-52840-9_8 sha: doc_id: 29192 cord_uid: yxk040wl this chapter summarizes the results of a survey among 1,000 interviewed persons that was conducted in germany. the aim was to obtain a current picture of the population’s expectations from self-driving (automated) vehicles. twelve questions were asked to get an overview of the participants’ opinions on the potential of self-driving vehicles regarding climate impact, time and monetary savings, the willingness to use automated vehicles, as well as their safety and risks. the results are compared to the current state of expert knowledge. the main finding is that the german population is skeptical towards self-driving vehicles. in comparison to a scientific perspective, the population is underestimating the potential and possible benefits of automated vehicles, while the risks are assessed similarly. in the conclusions, the findings of the studyare assessed in view of the covid-19 pandemic. efficient, comfortable, safe and greenthere are high expectations for automated vehicles (avs) in scientific and professional expert circles. however, the population's view on avs is rather unclear. therefore, a study on the topic "automated driving in a smart city" was conducted to obtain a contemporary understanding of how the population is feeling about automated vehicles. within the study, a representative survey of 1,004 german residents was prepared and evaluated. the survey itself was run by forsa politik und sozialforschung gmbh, an established polling company in germany. they performed computer-assisted telephone interviews (cati) asking people to evaluate avs with regard to their potential to increase the quality of life in cities, in terms of time and financial savings, and finally, regarding the reduction of traffic jams. furthermore, the interviewees were asked to give their opinion about the avs' safety and eco-friendliness, and to state whether or not they would be willing to use a self-driving vehicle. in addition to the responses to these questions, sociodemographic features were collected, including gender, age, level of education, and size of residence. concurrently, the topics of the questions were analyzed by performing an in-depth literature review. thereby, the results of the citizen survey could be compared to the latest state of expert knowledge. in this study, only the highest levels of road vehicle automation were considered: sae levels 4 and 5 in which no human driver is required. furthermore, different scenarios of how automated driving could affect the future of mobility were identified and analyzed. these form the basis for the assessment and evaluation of the survey results: scenario 1: driverless vehicles used privately in this scenario, there is no significant change in the current usage of vehicles. the only difference is that there is no human driver to perform the driving task. one person, household, or company will own the vehicle, which will be used for single trips and parked for the remaining time [13, 14, 20] . in the second scenario, a driverless vehicle is rented just for the time of the ride [20] . the vehicle is no longer owned by a particular individual, household, or company. in this case, the trip is a service (mobility-as-a-service). it is possible that the vehicle is issued to one person only, or that it is shared with other travelers (ride sharing). here, avs are used in addition to the public transportation system, which remains like today [3, 14] . while the majority of the journeys will be covered by the public transportation systems, smaller avs will serve to link areas to the greater transit systems. in the third scenario, the boundaries between motorized private mobility and public transportation are blurred. as travelling with avs will become convenient and cheap, users may no longer have any particular motivation to use mass transportation systems. instead, all trips will be made using self-driving, often shared, cars. the public (mass) transportation systems will be used less then today [4] . from an economic point of view, it is not very likely that the first scenario will come true. it is estimated that the cost of an av will be 3,000-6,000 us$ higher than that of a conventional car [5] . due to this higher up-front investment, it is more probable that people will prefer a short rental over purchase of an av. a counterargument against the third scenario is that the possible positive aspects of self-driving vehicles will be undone if the usage of small vehicles for individual mobility increases, simply due to the high additional congestion caused by those cars. thus, it is assumed that avs will rather be used where they complement an efficient public transportation system, as described in scenario 2. in this paper, the results for the most relevant four of the twelve poll questions are presented 1 . for each of the topics, first, a diagram is shown that depicts the responses to the asked question. after that, the survey results are summarized, and any differences between the answers of male and female interviewees are highlighted. in addition, the responses of the different age groups (18 to 29-year-olds; 30 to 44-year-olds; 45 to 59year-olds and 60 years or older ones) are examined briefly. since no differences could be found for the sociodemographic features educational level and size of residential location, that data was not evaluated. the first relevant survey question asked was: "how high do you assess the potential of self-driving vehicles to enhance the quality of life in cities, e.g. due to smoother traffic flow?". according to the survey results (see fig. 1 ), 42% of the interviewed persons think that the potential of self-driving vehicles to enhance the quality of life in cities is high (29%) or very high (13%). in contrast, 55% think that the potential is low (37%) or very low (18%). females are noticeably more skeptical of whether avs can enhance the quality of life in cities. 58% of the interviewed female persons think that the potential is (very) low, whereas 50% of the male respondents think the same. there are age-related differences as well: 63% of the 18 to 29-year-olds see a very high (29%) or high (34%) potential of avs to enhance the quality of life in cities, but only 29% of persons aged 60 or older. current scientific and professional expert knowledge tells that avs can improve the autonomy of people with reduced mobility. people with disabilities or limited mobility, as well as the elderly and children, may be able to travel more independently in avs because as they may not be depending on an accompanying person anymore [9] . an av could also be called and used independently if the necessary equipment is installed. another positive aspect is that avs can increase the safety of non-motorized road users. since self-driving vehicles will obey the traffic rules and will keep an appropriate safety distance to other road users, e.g. cyclists or pedestrians, their subjective safety will be enhanced. this is possible because the current forms of motorized intimidation, driving too close, abrupt stops, and other user mishapswill be avoided [1] . furthermore, urban centers with high traffic and residential density could be relieved. due to the higher driving comfort provided by avs, people may be willing to live in more suburban areas instead of the city center [2] . important for this would be that the higher mobility demand is served by an overall efficient transportation concept that is sustainable, and thus includes not just avs but also emission-free vehicles and a high-performance public transport system. additionally, avs can cause a reduction of parking space. if scenario 2 comes true, the space needed for parked vehicles will be significantly lower than today. in germany, only 9% of the current vehicle fleet is used at peak hours [17] . by reducing the amount of vehicles, the space that is currently occupied for parking will decrease. in addition, special automated valet parking garages may arise, in which an av would not occupy more than one quarter of the space a conventional car would need. this is possible, because the space for the access roads and ramps, as well as the space around the car could be strongly reduced as security spaces can be removed, and no human (driver) needs to get in or out of the car. besides, the ability to communicate with each other and with the infrastructure elements can lead to a smoother traffic flow. thus, traffic-jams are less probable and the people will spend less time in cars for the same trips. in summary, experts have identified several positive effects that avs can have on the quality of life in cities. apparently, the possible benefits are not obvious to the population, which in general underestimates the potential as shown by the survey. since the citizens are the potential users, the public's awareness of the potentials of avs should be raised. the aforementioned and the possibility to experience a functioning systeme.g. at field tests, would enhance their acceptance. if the avs are better usable for citizens and the positive effects become visible, the acceptance can be expected to rise significantly. the second most relevant question to the interviewees was: "can you personally imagine to use a self-driving vehicle?". on this question, the survey found that 45% of the interviewed persons can imagine using a self-driving vehicle and 54% cannot (see fig. 2 ). males are specifically more willing to use an av. 54% of the questioned male persons stated that they would use an av, but only 36% of the females did. with increasing age the willingness to use a selfdriving vehicle decreases. while 61% of the 18 to 29-year-olds can imagine using a self-driving vehicle, only 36% of the interviewed persons who are 60 years old and above can. the assessment of the matter from the scientific and professional experts' perspective reveals that societal acceptance is an essential prerequisite if avs are to be used ubiquitously. as stated in sect. 2, the realization of the first scenariowhere the ownership and use of avs would be the same as with a conventional car todayis rather unrealistic. market potentials will arise if economic advantages and safety gains become visible. if barriers of accessing and using the vehicles are kept small, acceptance of avs may be expected to rise, and one of the scenarios 2 or 3 will come true. this implies that automobile manufacturers may need to adapt their business model, as sales volumes of automobiles may decrease and the manufacturers' role changes from sellers to service providers for e.g. car sharing. in this situation, the automobile manufacturers are lending a car for a limited period, and the users only pay for the ride. the automobile manufacturers are in charge of cleaning, maintaining, and refueling the vehicle. the current automobile ecosystem with oems, car sharing providers, taxi companies, and leasing or car rental companies would thus face significant change. it should also be noted that many potential advantages of self-driving vehicles highly depend on their future usage: besides the positive effects mentioned in sect. 3.1, avs would increase the capacity of the current roads: as avs will be able to communicate amongst one another, the speed can be adapted according to the traffic situation, thus avoiding slow-moving traffic [7] . also, vehicles have the highest fuel consumption when accelerating at a traffic light or in stop-and-go-traffic. by optimizing the driving behavior and reducing the acceleration and braking phases, the fuel consumption would thus decrease. depending on the driving behavior of a human driver, avs have the potential to reduce the fuel consumption by 15 to 30% [7] . at the same time, it is possible that avs will travel in convoys. by communicating with other vehicles, the space needed for stopping can be reduced, as other vehicles can be informed about acceleration and braking actions in real-time. thus, the reaction time in an av platoon can be shorteror rather equal to the latencythan in conventional vehicles. velocity peaks when driving in convoys, and the effective driving time can be reduced [2] . as a consequence, the capacity of roads could be increased by 40% in cities and 80% on highways when all vehicles were driverless [12] . due to the better traffic flow and increased capacity, the number of traffic jams could be reduced. an intelligent routing system, where the vehicles are distributed according to the roads capacity, would further contribute to this gain in capacity. also, routes could be selected that are shorter or where fewer stops are necessary [7] . in conclusion, according to the survey, the population in germany does not yet show a high affinity for the technology of self-driving vehicles. the ambivalent survey results reflect this. how avs will be used in the future is currently an open question, but many optimization potentials are strongly dependent on that. a smoother traffic flow and fewer traffic jams are only possible if a substantial amount of the vehicles on the road are self-driving. it is also estimated that trips with avs will be relatively cheap [10, 15] . at the same time, the current advantages of the public transportation systems the possibility to read or to do something except for performing the driving taskwould also applicable for trips in a private vehicle if it were self-driving. if all the trips would be performed with smaller, individual avs, the possible positive effects will be undermined, though, and rebound effects will come to pass. as a result, the advantages of avs would be reduced. to counteract that, the attractiveness of public transportation systems needs to be increased such that the main trips are performed with mass transportation systems, and only a few with avs for individual transportation. the third of the most relevant questions in the survey was: "driverless vehicles can be the aim of hacker attacks. do you agree?". the survey results show that the population is seriously concerned when it comes to the cyber security of self-driving vehicles. 80% of the questioned persons agreed to the statement that driverless vehicles can be the aim of hacker attacks (see fig. 3 ). of these persons, 39% agreed and 41% agreed to the fullest. only a small part (17%) of the interviewed persons does not think that avs are open to hacker attacks. interestingly, this is the only question for which the answers of the male respondents were more pessimistic than the female. 83% of the questioned males think that avs can be attacked by hackers, but only 78% of the females do. furthermore, it was surprising that the answers did not differ between the age brackets. overall, that was the question with the highest consensus among the different groups. many expert discussions about avs are focusing on the topics privacy and data security in particular. the av's functionalities are built on cameras and other environmental sensors, controllers and data from the cloud to analyze traffic events, and to detect other road users. with a higher degree of automation, more interfaces to controllers are necessary, leading to a higher number of potential weak spots. hackers would thereby be able to access sensitive personal information, driving data, or other connected devices like mobile phones. at the same time, the hacker attacks could also be targeted to manipulate the system and cause personal injuries. from the populations' point of view, privacy is a very sensitive topic. the german federal government recently summoned an ethics commission that is supposed to give advice on whether automated driving is socially acceptable and desirable or not. one result was that sufficient data protection for all road users needed to be guaranteed the acceptance of avs. furthermore, it would be required that any person involved gives their consent before his or her data are released [6] . this means that the automobile manufacturers have to make great efforts to protect the privacy of the avs and the road users they interact with. at the same time, the collected data can be an opportunity for the public authorities. the evaluation of traffic data of avsanonymized according to the data protection regulationscan help municipalities to control the traffic and optimize the infrastructure [8] . to conclude the findings on this question, cyber-attacks on self-driving vehicles can aim at interfering with the driving behavior, but also at intercepting personal data. the concerns of the population are widely shared by the scientific and professional expert community. given the fact that hackers can assume the control of securitycritical functionsspecifically acceleration, steering, and the brakesself-driving vehicles should be treated as critical infrastructure elements that are subject to high requirements and scrutiny. the higher it security requirements would go along with higher production costs, but would minimize the risk of non-authorized accesses at the same time. the fourth and final question cited from the survey, here, was: "the road safety in cities can be improved by using driverless vehicles. do you agree?". according to the survey results (see fig. 4 ), 51% of the interviewees think that the road traffic will become safer when avs are used. 36% of those asked agree that the road safety in cities can be increased by using driverless vehicles, and 15% agree to the fullest. this question shows the highest discrepancy between women's and men's opinions. 62% of the interviewed male persons think that self-driving vehicles will make the traffic safer, whereas only 42% of the females agree with that statement. noteworthy as well is that the consent to that statement is decreasing as age increases. of the interviewed 18 to 29-year-olds still 73% agree with the statement, but only 42% of the persons who are 60 years old or above do. according to the scientific and professional expert knowledge, the most important benefit of self-driving vehicles is that they will increase road safety. according to several studies, more than 90% of road accidents are caused by human error [18] . because more and more driver assistance systems are usede.g. anti-lock brake, electronic stability control, lane departure warnings adaptive cruise control, or driver fatigue detectora reduction of the number of accidents is already noticeable. by using the emergency braking assistant, e.g., at least 20% of the passenger car crashes can be avoided [16] . thus, it can be assumed that further automation will minimize human errors while driving and the road safety will increase. in public debates of the decision-making criteria of avs, it is rather the ethical aspects, such as the following questions that are much discussed: how will the selfdriving vehicle 'decide', if it has the 'choice' to run into a child or an elderly person? which moral decisions can be made by avs? and, who is liable when an accident occurs? the ethics commission mentioned before was appointed to answer these questions. an essential outcome was that nobody, neither human nor machine, would be allowed to balance between lives in a dilemma situation. hence, no rules or decision making processes can be programmed into the software. the same commission concluded that automobile manufacturers are liable for accidents that occur while driver assistance systems are active. therefore, it has to be clear who is in charge while driving, the vehicle system or the driver. this information needed to be documented and saved at all times [6] . for the conclusion, it should be noted that the german traffic safety association in 2007 stated the 'vision zero'. the aim is that there are no more fatalities or serious injuries in road traffic [11] . to achieve that objective, drastic measures still have to be taken, as there are still more than 3,000 road fatalities every year in germany [19] . one option seems to be to use self-driving vehicles given their promises of higher safety. from that point of view, the use of avs would be preferred. though, it is important to note is that it still has to be proven that a driverless vehicle is safer than human drivers in a majority of the traffic situations, particularly in complex environments such as cities. therefore, extensive real and virtual tests will have to be made to validate the system's performance. only after that, the user acceptance will rise. of further interest is that even though more than half of the interviewed persons think that road safety can increase by using self-driving vehicles, only 44% can imagine using an av. that allows the combined conclusion that an increase in safety is not necessarily a decisive factor for using avs, at least not in view of the respondents to the poll. this is making clear again, that public awareness of pros and cons will be essential for a wide acceptance and deployment of avs. the automation of vehicles is going to change urban life tremendously in the future. it promises an accident-free traffic, optimized traffic flow, and inclusive mobility services. to understand how the german population is feeling about avs, a representative survey was conducted, which was further compared to scientific and professional expert knowledge in a technical assessment. a central outcome was, that the population is underestimating the potentials of avs compared to the current opinion in the scientific community. furthermore, differences in the answers were found that are connected to sociodemographic features of the interviewed group, with females in general being more skeptical towards avs and their potential. at the same time, those questioned between the ages of 18 to 29 were more open to the new technology, and further assessed the potential of avs more positively. the older the interviewed persons were, the more critical they were. other sociodemographic features like the educational level or whether the person lives in rural or urban environments did not correlate to their answers, though. the only question where less deviations between survey respondents and expert knowledge were visible is the question about cyber-security. in general, it is possible that the poll showed a general skepticism towards robotic technologies and not specifically towards avs. to find that out, further research would be needed, while surely more efforts need to be placed in creating public awareness of the pros and cons of avs. it should be noted that the study was conducted in 2019 before the beginning of the covid-19 crisis. during the pandemic, the worldwide mobility demand changed significantly, with a massive drop in passenger numbers in public transportation systems and shared cars. in sight of these circumstances, it is questionable, whether the survey results would still be the same, today. it is self-evident that mass transportation systems are used less, because it is hardly possible to keep the safety distance in a confined space. furthermore, there are concerns about the cleanliness of vehicles. as an alternative, the usage of bikes and private cars are increasing. in many cities, roads have been transformed into pop-up pedestrian zones or bike lanes, such that those using the soft modes can keep distance from one another. during the pandemic, a scenario of individuals using small and shared self-driving vehicles instead of public transport may appear the most appealing. a reduction of the usage of car and ride sharing, as well as taxis and other mobility services is noticeable, though. an explanation might be that the population has doubts, whether the vehicles are disinfected properly. so, selfsanitizing capabilities might be a very relevant feature of avs in the future. it should be considered, though, that overall mobility has shrunk by up to 40% temporarily during the pandemic, because people worked from home, schools and shops were closed, and private meetings were prohibited, all affecting any kind of transportation service. hence, it is difficult to derive a clear change in the survey results from the behavior during the pandemic. while it is well imaginable that individual transportation in a shared av could be more appealing now than before the pandemic, this conclusion cannot be made easily, as demand in shared vehicles has been dropping, too. overall, it is likely that the skepticism towards the new technology and especially the concerns about the cyber security of avs remain, and that any new features that appear beneficial in response to covid-19 will not necessarily be met with enthusiasm only by the population. this insight that is clearly calling for a stronger involvement of citizens into the advancing av design process applying co-creation approaches. automated vehicles and the rethinking of mobility and cities autonomous vehicle technology: a guide for policymakers integration of shared mobility approaches in sustainable urban mobility planning einführungsszenarien für höhergradig automatisierte straßenfahrzeuge autonomous driving. disruptive innovation that promises to change the automotive industry as we know it -it's time for every player to think:act! bmvi: ethik-kommission. automatisiertes und vernetztes fahren an analysis of possible energy impacts of automated vehicle datengetriebene geschäftsmodelle rund um das vernetzte auto. grundrechtsschutz im smart car. d autonome fahrzeuge und autonomes fahren aus sicht der nachfragemodellierung urbane mobilität und autonomes fahren im jahr 2035. welche veränderungen durch robotaxis auf automobilhersteller verkehrliche wirkung autonomer fahrzeuge system effects of widespread use of fully automated vehiclesthree scenarios autonomes fahren und stadtstruktur mobility-as-a-service: why self-driving cars could change everything der beitrag des automatisierten fahrens zur erhöhung der verkehrssicherheit. grundrechtsschutz im smart car. d mobilität in deutschland -mid ergebnisbericht elektrifiziert, automatisiert, vernetzt -herausforderungen und chancen für die antriebsentwicklung von morgen. vpc -simulation und test unfallentwicklung auf deutschen straßen research to examine behavioral responses to automated vehicles automatisiertes fahren in der smart city. iit acknowledgements. the authors gratefully acknowledge support by the verein deutscher ingenieure (vdi) who initiated this study. they are also indebted to the members of the institute for innovation and technology (iit) of vdi/vde-it in berlin for their assistance, especially to lorenz hornbostel and volker wittpahl for managing the project, as well as to doris johnsen and jörg dubbert for their contributions to the state of expert knowledge assessments. key: cord-034566-rfncgtnf authors: sarukkai, sundar title: self-reliant india: self of a nation or a national self? date: 2020-11-02 journal: j doi: 10.1007/s40847-020-00115-z sha: doc_id: 34566 cord_uid: rfncgtnf the pandemic has led to a renewed reflection on what it means to be self-reliant in terms of our everyday practices. nations too follow this logic in their own claims of self-reliance. this paper discusses the implications in these claims of self-reliance in the context of the nation by positioning this claim within the tension between two different formulations of the self: self of the nation as against the idea of national self. although there is an increased push for self-reliance globally these days, the idea of being self-reliant is a long one. the relationship between the independence movement and selfrule is an expression of political self-reliance. the latest invocation of self-reliance by governments in india and elsewhere is primarily about economic self-reliance but like in the indian case it is more specifically about self-reliance in manufacturing. but the nature of self-reliance is such that it is difficult to understand economic self-reliance without other forms of self-reliance, most importantly, a self-reliance of the 'self' as well as of the 'intellect'. it is this range of ideas that are present in self-reliance that needs to be understood, even for the narrow vision of self-reliance in manufacturing or other economic processes. in the context of the self-reliance of the nation, there is a new conceptual challenge that we have to face, namely, the use of the term self in the context of the nation. what work does the term 'self' do in the articulation of self-reliance of a nation? how does the nation get or possess a self, since the self is most commonly seen as the attribute of individuals? does this imply that the nation gets unified as an individual even though the nation is a collection of individuals? and does the association of self to the nation lead to contradictions for a democratic nation? in this essay, i want to explore the notion of self-reliance in the context of the nation in a very limited way. on the one hand, the term 'self-reliance' needs little philosophical reflection since its meanings are seemingly apparent. in fact, in our common usage of this term, the word 'self' plays very little part. it primarily functions in terms of insideoutside: self-reliance means nothing more than not to be reliant on the outside (others) but even this simple meaning has deep assumptions about inside-outside, self-other and so on. while this is a common usage of this term, in this essay i want to argue that there is a hidden function of the many meanings related to the self. these multiple approaches and paradoxes about the self arise in the many different questions about self-reliance. there are many different ways to understand the meaning of 'self', ranging from the ontological to the narratological. i do not want to enter into these different formulations but will focus on one implication of invoking the self in a term that has pragmatic considerations for the functions of a nation. i begin with some reflections on the question of the self during covid. what i say here are some preliminary remarks to motivate the reason for critically focussing on the meaning of self in self-reliance. then i try and attempt to understand why the notion of the self (which is so much related to the individual) is invoked in the context of the nation. what is in the understanding of a nation that allows the possibility of linking the nation to a self? i suggest that there are two primary ways of understanding the meaning of a self in relation to the nation: self of a nation and a national self. the implications of these two formulations are quite distinct and have differing implications on the meaning of self-reliance. the covid-19 pandemic has created a special problem that has to do with the relationship between the self and the society. the social pre-covid was a field which catered to individual interests-from security, health, infrastructure and travel to shopping. what the pandemic really destroyed was our access to the social world, a world in which others performed their work on behalf of others. labour itself was oriented around this act of distributing the tasks that one had to do for oneself. restaurants took care of the individual's need for cooking one's own food, schools took care of the children (at least for a major part of the day), hospitals took control of health (much of which could have been in the hands of individuals themselves) and so on. pre-covid we were a society that increasingly developed a sense of the social defined through dependency. that was not a social that came together through friendship or kinship or as members working towards a common goal. the society itself was moving more and more towards not just a service economy but a service society, where the very idea of the social was reduced to a system designed to take care of the interests of individuals. shopping malls were a literal exemplification of this social in urban areas. technology plays a major role in this subordination of the individual to the society since the basic functions of the individual were outsourced to technology. right from the beginning, the ideal of technology was to replace manual labour-labour characterized as routine, as a drudgery and not having sufficient value. thus, labour associated with hard physical work was slowly replaced by machines and household labour by women was taken up by technologies such as the washing machine. the aim of this view of technology was that eventually all human actions-particularly those that were repetitive and monotonouscould be completely outsourced to machines. this view of technology has become so much a part of our very understanding of a society that the great chess player, gary kasparov (2017), in his book deep thinking extends the promise of new digital technologies by arguing that now they can take care of 'menial' mental tasks which includes the human capabilities of memory, recall, calculating and so on. technology became an important part of the society in that it made possible the worldview that saw the social world as a world which was there to take care of, protect and more increasingly entertain individuals. in this view of society, not just the government but also other people in a society had become like technology-they were all cogs who took care of one or the other of the jobs to support the interests and desires of the individual. the fact that any social based on this utilitarian end is inherently hierarchical only meant that this form of the social was always geared towards protecting the interests and desires of the more privileged. the pandemic rudely halted this unquestioned function of society. it first squeezed off the subletting of individual action to others. people who did not know the basics of cooking had to learn them. those who saw shopping as a social interaction found that the most taken for granted liberty-the 'right' to shop-was suddenly removed. there were no gyms for exercise and one had to find ways to exercise by oneself in the confines of their house or in the restricted space of their apartment blocks. social distancing literally distanced the social from each other's lives. the claim that this was not really social distancing but only physical distancing misses the point about the impact of the presence of individuals in the creation of the social. the anonymous and virtual social of social media, mediated through digital technology, was just a two-dimensional caricature of the real social that characterizes human relations. this phenomenon is not new and can be seen occurring repeatedly in discussions on the idea of 'presence' in theatre in contrast to films, for example. but just as the social was being distanced, there was a concomitant discovery of the individual and a revival of that worn-out cliche, 'discovering oneself'. it was as much a discovery of what one could do by oneself, tasks which were originally expected to be done by others-whether it was laundry, ironing one's clothes, carrying out garbage and for a lot of people just sweeping and mopping. many of these chores were not easy but at least it became clear why they were not easy. i do not believe that we will learn lessons from this forced reallocation of labour practices, which ideally should make us respect the people who do these jobs for us more than before. once the situation normalizes, we will go back into the surrogate world of the social but at least now we are forced to confront how much of the individual self has been mortgaged to others in the name of labour and service. what does this re-discovery of the self imply for the future ideas of the social? it is quite instructive to see what has happened to the hospital services during this time. hospitals which were full of patients seeking treatment for something or the other suddenly found that many who would have otherwise landed up for consultation preferred to wait or depend on home remedies. although the covid has had some negative impact on those who needed urgent medical intervention, overall the number of people who discovered individual practices to help them fight their problems increased. this was one direct mode of the strengthening of the individual and this included changes in lifestyle practices including exercising, control over food, etc. in other words, the pandemic allowed us a chance to rethink what it means to be self-reliant with respect to our own selves. however, the meaning of being self-reliant depended to a large extent on the modes of the discovery of the self as described above. while it might seem that the examples above point to a 'strengthening' of the self, it is not necessarily the case. i used these examples only to show how a re-organization of our everyday understanding of the self happened through these responses to the covid situation. as i also mentioned above, these new examples of self-reliance came in response to the prior situation of our society functioning largely as a 'service society' as well as the deeply social nature of individual lives in places like india. one could also argue that the covid situation actually created more selfishness and antisocial tendencies in our society leading to important ethical problems. 1 what these tendencies point to is the confusion in the meaning of self-reliance. in the examples discussed above, we can note the processes of strengthening the self and also becoming more selfish. but how do these qualities affect the question of reliance, being reliant upon? what i would argue is that the very notion of reliance implies the social and self-reliance is only about strengthening the self as a social actor whereas being selfish is relying on the self in a world of just that self. in a similar analogy, we can think of self-reliance of a nation as being totally inward looking and acting as if other nations do not exist or we can consider it as acknowledging that the nation is part of a global system and yet is able to be selfsustaining. thus, while the covid period has led to selfish practices there has also been the possibility of expanding one's own awareness of the self in relation to relying on others. what happens to us as individuals happens to nations also. 'make in india' was already a saleable slogan. trump had further legitimized such slogans through his own version of 'make in america'. make in became a new slogan of legitimate nationalism. the pandemic, as much as it shone a spotlight on the social dependency of individuals, also made nations realize how much they depended on other nations. the global was always a lot like the social-it was not really based on notions of friendship, ideas of kinship or a sensitivity to the common humanity but was more utilitarian and driven by dependencies. suddenly we realized that in the great story of indian pharma producing cheap drugs, there was another story of dependence on china for a major part of the raw material for these drugs. the finance sector is anyway so globally wired that the very idea of strengthening the nation like strengthening the individual would be a non-starter. the market economy drives so much of the idea of the global that in spite of market crashes few are worried as they all realize that the world we have created is not possible if the market dependencies are over. however, as i argued earlier, the pandemic also revived more strongly the spirit of individual self-reliance as against individualism as a social practice. this recognition of the possibility of individual strength is also a model for the revival of the strength of a nation. and the most powerful example of the strength of the nation-in the model of the individual-lies in the 'self-reliance' of a country. but what is the meaning of the self here? why invoke the idea of self-reliance of a nation when the very idea of the self of an individual is itself so complicated? what task does the term 'self' perform in these articulations? we can begin with the reasons why the self is invoked in the context of the individual. what role does the 'self' perform in the case of individuals? why do we even invoke this term? i will not enter into a debate on whether we should make an ontological commitment to the self but only discuss the reasons why we tend to invoke the notion of the self. the self helps us make sense of some of the experiences we have such as the feeling that experiences happen to 'me'. the use of the notions of me, mine and myself are indicators of the action of a self. thus, self marks the basic identity that one has of who they are. but there are also other important reasons for our naive invocation of the self: unity of the senses that is presupposed in the belief that different experiences (such as seeing, hearing, touching, etc.,) all happen to the 'same me', that all experiences over time (from the time we are born) happen to the 'same me' and so on (bhatt 1962) . the self generates a notion of the unity of the experiences that are part of our lives and gives us a sense of identity. it gives us a sense of 'ownership' over our experiences (guru and sarukkai 2012) . it helps us to understand the nature of human action and human agency, such as the question 'who' is acting. we could go to the extent of saying that the basic notions of the unity presupposed in an object is one that is modelled on the self. an object is nothing more than a collection of different qualities, such as colour, shape, size and taste. so, what is the object other than these qualities? how do these qualities all belong to 'one' object? this cognitive inclination to unify diverse qualities in one is common to our basic recognition of objects (and therefore the world) and the self. we talk about the social in pretty much the same way (guru and sarukkai 2019). we use terms like 'we' and the 'we-self' just like we talk about i and the i-self. we belong to a social in ways similar to that in which different experiences belong to the same individual. the very idea of a nation with concomitant ideas such as 'belonging to the nation' is based on these beliefs about the self. so, it is not a surprise when the nation repeatedly invokes ideas of self-rule and self-reliance for these are all assertions of the self. there is an important characteristic of the sense of unity which is an essential element of the notion of the self. an individual has a wide variety of experiences. this diversity of experiences, some of which may be pleasant but some undesirable like experiences of sickness or sadness, are all unified, however diverse they are. the unification that is the core of the idea of the self is not a unification based on reducing all the experiences to an idea of sameness. rather, the unity is one that is based on the idea of the self as the substratum of all experiences. all experiences that we have are unified not because these senses have common elements but because they are all 'located in oneself'. this idea of unity is extremely important when we talk about the self of the nation. the nation is most fundamentally defined by a sense of unity and identity. the nation borrows its vocabulary of belongingness from the notions of a self. but this is of a social self and not the individual self. a social self adds an important component to a forgotten aspect of the individual self. this is the aspect of responsibility to others who are part of the social self. for traditions which have engaged deeply with the question of the individual self, there is a sense of self-responsibility which is extremely important. the individual self experiences but also regulates itself. (this can be contrasted to the culture of 'me and mine' that is a particular understanding of the self where there are no questions of selfresponsibility.) in the case of a social self like the nation, the regulatory aspect becomes most problematical since it raises a question of who is going to regulate the actions made on behalf of the nation, the socialized self. the concept of the nation has always had a parasitic dependence on the notion of the self. in the independence movement, it is most prevalent in the debate on self-rule. the idea of self-rule is self-explanatory: in both these terms which use the word self, the meaning of the self is in opposition to the outside(r). self-explanatory means that there are no external requirements to understand an expression and self-rule is about the capacity to rule one selves without the assistance of the outsider. (it is important not to conflate the outsider and the other in this context.) the idea of self-rule is an essential component of any notion of the nation since the nation, by definition, gets defined with respect to the insider-outsider dichotomy. gandhi's understanding of self-rule illustrates the need for invoking the idea of self in the context of the nation. one of his most influential works, hind swaraj, is a handbook for self-rule as indicated in the title itself. the list of terms that work around the idea of the self become defining elements of the independence movement: terms such as swaraj, swadeshi, swabhiman. the reason that self or the prefix swa is so important to these articulations is because within the idea of self there is a notion of both freedom and governance. the self is an excellent example of responsibility with freedom since the self will indulge in what it wants but has a core of survival within it-what we refer to as self-preservation. the fight against the british is not captured merely by the word 'independence'. the indian language connotations for this word include swatantra and swavalamban, both of which have an explicit grounding in the self. this necessary connection with swa locates the principal idea of independence within the self first and thus all invocations of swaraj by gandhi and other leaders have to be understood not just as liberation from the british but as an essential practice related to freedom and responsibility of the self. an important addition to this debate comes through the tension between gandhi and ambedkar. nagaraj (2012) captures this tension through the invocation of two terms derived from the self: self-rule versus self-respect. the distinction between these two terms has a significant impact on the very definition of freedom and its relation to the self. selfreliance (and the expressions of make-in) in the context of the nation has elements both of self-rule and a strong dose of self-respect. much of india's rhetoric on self-reliance (especially the make in india kind) is a call for self-respect within a hierarchy where india is placed low in the order. self-reliance in this context is not self-rule but only about assertions of self-respect. self-reliance is closely related to the ideas of swaraj. it is a reaffirmation of the idea that ruling itself has to be from within and by oneself. one is free and accountable to that freedom at the same time. much depends on what we mean by the self here. for gandhi, ruling oneself meant disciplining the self and that includes the responsibility of the (individual) self. being self-reliant does not mean asociality but only the responsibility of oneself for oneself. but how is it possible to be self-reliant? what are we supposed to be self-reliant about? these questions become important in the context of the self-reliance of a nation. we can glimpse the contours of this question in the philosopher k. c. bhattarcharyya's (kcb) essay 'swaraj in ideas' (bhattacharya 1984) . this was an essay which has been understood in different ways but the fundamental question that bhattacharya poses is the possibility of thinking about our society in ways that do not draw upon the 'outsider'. he suggests that the foreigner cannot understand the indian society like 'we' do and that drawing upon the resources of the society might offer a better understanding of the society. as raju (2017) points out, kcb should be seen as responding to the crisis of organic thinking and organic solutions to the problems of our society. independence is not limited to political independence but also needs the independence of the mind. the independence of the mind can only be supported by a self that is self-confident, that can feel secure in the foundations of its philosophies and experiences. there can be no swaraj without swaraj in ideas, in worldviews, in projecting the future which we want and not based on the interest of 'outsiders'. it is as much a question of self-articulation of who we are and what our vision of the world will be. while there are many points which may be debated in this view, it is nevertheless an important theme that will arise in any claim of self-reliance. perhaps the most important point in this idea of self-articulation is the problem of articulating on behalf of others who constitute the 'us' and 'we'. who is going to speak on behalf of a group, a community, a society, a nation? what kind of a social self will be allowed by the individuals to speak on their behalf? nation is one of the most powerful illustration of the action of a social self and thus the meaning of a nation becomes as complex as that of the individual and social self. i believe that there are two functions of the term 'self' in the context of the nation: one referring to the 'self of a nation' and the other to 'national self'. the difference between these formulations is quite stark and impacts the way we understand self-reliance in the context of the nation. when references are made to the self of a nation, it is primarily about the qualities of the nation related to the themes of identity, belongingness and the space of experiences for those who live and/or belong to it. in this sense, it is analogous to, and possibly modelled on, how one understands articulations of oneself. on the other hand, the national self does not refer to the nation at all but is more a reference to some quality of the individual selves. it is a quality of the members of that nation and is not really about the self of a nation per se. depending on the meanings we ascribe to self, we can discover different meanings for self-reliance in the context of the nation. why would we even invoke the notion of self in the context of the nation? what can accommodate a meaningful understanding of the self when it is used in the context of the nation? at a pragmatic level, it is easy to see why the invocation of self is 'natural' for a nation: we refer to a nation as 'my' nation and so concepts of my, mine, mineness and related issues of identity arise for the nation in a way similar to that of the experiences of the individual self. but at the same time, the self related to the nation also refers to a we-self, a self of a larger social. it is also an embodied social and this quality makes it different from other social selves. just as the individual self is embodied in the physical body, the self in relation to the nation is embodied in the physical nation, with its geographies and boundaries. but it is also precisely because of these characteristics, that the self in the context of a nation has to accommodate plurality, diversity. this quality again distinguishes the self of the nation from other social selves related to gender, caste and religion, for example. this self which can accommodate plurality and difference is one that functions as a substratum and does not insist on sameness. it is the quality of ashraya-a shelter for the multiple, diverse individuals, practices and traditions. the self of a nation is this true shelter, the foundational substratum where unity is possible only because of a sense of feeling that it is happening to all of us. however, this is not the only notion of a self that is possible in the context of the nation. there is also another possibility, one that is often imposed on individuals. the nationinstead of being seen as a collective social-can be reduced to a quality of the individual. in this case, it is not a self that stands 'outside' the individual. a self which incorporates the nation within itself is a national self and thus is one quality of a self, a quality that is hegemonic and imposed. it arises through the cognitive act of an individual and is most often not directly related to their experiences. but the power of the (internal) national self as against the (external) self of the nation is that it evokes deep emotions within the individual. the self of the nation is a recognition of a more complex, plural self that operates outside the individual but yet one in which the individual is part of. whereas the national self incorporates the nation within the self and thus creates a sense that the nation belongs to 'me'. so, when certain individuals start speaking on behalf of the nation-what the nation should be like, what people living in that nation should do and should not do-they are illustrating the functioning of the national self. nationalism in its most troublesome form arises through the formation of a national self. these are not merely some abstract formulations about the self and the nation. these notions of the self are invoked in the rhetoric of self-reliance and my argument is that the two different meanings of the self in relation to the nation create different meanings for 'self-reliance'. if the meaning of self in the expression 'self-reliance of the nation' is referring to the 'self of the nation', then self-reliance cannot be just about producing what we need for the citizens of this country. it also means a discipline of the self of the people in the country, and this is a civilizational and axiological task. it is about values in a society and not material production. these qualities, taken, for example, from gandhi, tagore and others, would imply a very different meaning of the nation where the nation is not one which is homogenized, is violent, is hierarchical, is non-egalitarian, is consumerist and so on. as parel (2000) points out, gandhi's formulation of self-rule had four components, three related to independence of the nation, economic freedom and political freedom but the essential fourth component was self-rule, here seen as the rule of the individual self by the individual self. this self-rule included the important quality of self-control including control of the body and the desires of the senses, control over thinking and so on (banerjee 2020) . why should this difference matter? it matters because these two versions of the self/ nation relation have implications for the meaning of self-reliance. what does it mean to be self-reliant? the simplest answer is to be independent of others. but what is the independence from others that we are seeking? the nation can be independent from others in the products it produces, in its economy, in its policies and so on. but this does not really encompass the many meanings of swaraj that we talk about. as kcb points out, it is equally important to have swaraj in ideas, a freedom in the intellectual domain. are we anywhere close to having the freedom in the intellectual domain? we do not even produce knowledge and worldviews which matter to the rest of the world. it does not seem to matter to our own intellectuals and students. what are the ideas that drive the nation? where are the ideas being produced? how democratic is this source of ideas? is it able to include the visions and aspirations of not just the 'intellectual community' but also the everyday experiences of diverse communities in india? this is not a question about geographical origins but about philosophical origins. what kind of views about the nature of society, family, individuals should matter to us today when we imagine the future of the nation? the answer is not in the geographical 'outside' or the cultural 'inside'. it is not going to come from the 'west' or from the 'past' alone. the self-reliance that the government talks about is about factory goods but without the swaraj in ideas none of these are self-sustaining. self-reliance is not in manufacturing alone. it has to be the articulation of the self of a nation about progress and development, about educational goals for the future citizens of the country, about basic well-being of all the citizens particularly the dispossessed and the marginalised. what we need to 'make in india' are civilizational values, our own articulations of the idea of equality in an unequal society, a democracy that functions effectively, and anything else which can lead to a truly free, democratic and egalitarian society. to 'make' all this in a self-reliant manner is the true idea of a nation and the true self of a nation. the easier task is to reduce the self of a nation to one idea of a national self is but this is also the more dangerous. the national self is an individual self which understands the national as one quality of the individual self. but a nation cannot be a quality of a self because it reduces the nation to the interests of individuals. in such a case, the nation as such cannot acquire a unified self just because all the people in the country possess one national self. the self of a nation is one that is self-reliant in the true sense of the term, one that is truly independent. tracing gandhi: satyarthi to satyagrahi. routledge, london bhatt gp (1962) the basic ways of knowing. motilal banarsidass, delhi bhattacharyya kc (1984) svaraj in ideas the cracked mirror: an indian debate on experience and theory deep thinking. where machine intelligence ends and human creativity begins. hatchette india, delhi nagaraj dr (2012) the flaming feet and other essays acknowledgements i thank the two referees for their insightful and critical comments which have helped me clarify some points in this essay. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-013473-8q0a33dr authors: hetherington, erin; mcdonald, sheila; racine, nicole; tough, suzanne title: longitudinal predictors of self-regulation at school entry: findings from the all our families cohort date: 2020-10-16 journal: children (basel) doi: 10.3390/children7100186 sha: doc_id: 13473 cord_uid: 8q0a33dr self-regulation is the ability to manage emotions, modulate behaviors, and focus attention. this critical skill begins to develop in infancy, improves substantially in early childhood and continues through adolescence, and has been linked to long-term health and well-being. the objectives of this study were to determine risk factors and moderators associated with the three elements of self-regulation (i.e., inattention, emotional control, or behavioral control) as well as overall self-regulation, among children at age 5. participants were mother–child dyads from the all our families study (n = 1644). self-regulation was assessed at age 5. risk factors included income, maternal mental health, child sex, and screen time, and potential moderation by parenting and childcare. adjusted odds ratios of children being at risk for poor self were estimated using multivariable logistic regression. twenty-one percent of children had poor self-regulation skills. risk factors for poor self-regulation included lower income, maternal mental health difficulties, and male sex. childcare and poor parenting did not moderate these associations and hostile and ineffective parenting was independently associated with poor self-regulation. excess screen time (>1 h per day) was associated with poor self-regulation. self-regulation involves a complex and overlapping set of skills and risk factors that operate differently on different elements. parenting and participation in childcare do not appear to moderate the associations between lower income, maternal mental health, male sex, and screen time with child self-regulation. the first five years of life have been identified as critical for healthy development, as they set the stage health and well-being across the life course [1] . a key developmental skill acquired in these early years is the capacity for self-regulation, which is defined as the ability to monitor and control emotions, attention, and interactions with others and the environment [2, 3] . these foundational skills, which develop from infancy and mature through adolescence, are critical to the development of positive relationships with family members, teachers, and peers [2, 4] . longitudinal studies of self-regulation show that preschoolers who could wait for two marshmallows instead of eating one immediately had higher educational attainment, lower use of addictive substances, and lower rates of obesity later in life [5] . other studies have found that poor self-regulation in the early years can increase the risk there are several identified risk factors for self-regulation in the literature. for example, lower income remains a consistent predictor of self-regulation skills. some studies suggest that economically disadvantaged children may have access to fewer resources and opportunities to engage in enrichment activities (e.g., dance classes or sports) that promote self-regulation skills [8, 11, 12] . additional research suggests that living in stressful or chaotic environments could impact self-regulation [13] . maternal depression has also been associated with the development of sub-optimal emotion regulation skills in children [14, 15] . mothers with mental health challenges may be less responsive to their children, and may not model appropriate positive social and emotional behaviors [16] . one large population based study in canada found that children of mothers with depression were less able to focus attention [17] . there is little information regarding the impact of maternal anxiety on overall self-regulation, or if the negative association between maternal mental health and self-regulation can be moderated by external factors. gender has also been identified as playing a role in the development of self-regulation. many studies note that self-regulation skills seem to develop later in boys with marked differences emerging in early childhood and persisting through middle childhood, but evidence on moderators is mixed [3, 8, 18] . finally, there is emerging evidence that screen time may impact self-regulation. two large scale studies found that increased television viewing was related to lower self-regulation skills [9, 10] . both of these studies measured screen time simultaneously with self-regulation and used short scales (five or six items) to measure self-regulation. longitudinal studies with robust measures of self-regulation are needed to better understand this association. this study focuses on two potential moderators of the association between risk factors listed above and child self-regulation: group-based childcare and parenting ( figure 1 ). previous studies suggest that childcare is associated with better behavioral outcomes, such as decreased physical aggression, lower hyperactivity, and higher prosocial behavior [17, 19] evidence from australia suggests that participation in childcare improved emotional regulation in children [20] . therefore, while evidence suggests that childcare may be beneficial for distinct elements, there is little evidence looking at the role of childcare at the larger construct of self-regulation. figure 1 . risk factors and potential moderators of self-regulation. risk factors (maternal mental health, lower income, child sex, and screen time) were measured at age 3 (or at birth in the case of child sex). group childcare (at age 3) is hypothesized to moderate the association between maternal mental health or lower income and self-regulation. parenting behaviors (at age 3) are hypothesized to moderate the association between child sex or screen time and self-regulation. previous research has examined the role of childcare as a moderator between low income and academic achievement, suggesting a potential effect on attention and cognitive skills [11, 21] however, it is not known if this moderation extends to other elements of self-regulation. the hypothesis is that childcare provides opportunities for children to interact in a structured environment with skilled providers, which facilitates development of emotional regulation and behavioral control. also, there is evidence that childcare can moderate the negative association between maternal mental health and behavioral control, however, the potential moderating role of childcare for overall self-regulation has yet to be examined [17] . parenting is thought to influence self-regulation through a modeling, interaction, and the emotional environment in the home [22] . parenting behaviors such as high levels of negative reinforcement and low levels of positive interaction are consistently associated with lower emotion regulation and greater behavioral challenges both in cross-sectional and longitudinal studies of children [23] [24] [25] . thus, it is possible that parenting practices may play a role in attenuating or exacerbating the association between male sex or screen time and children's self-regulation. in terms of parenting moderating the association between child sex and self-regulation, data from the longitudinal study of australian children found that harsh parenting did not moderate this association at ages 2 and 3 years [25] . similar results were found from the national longitudinal survey of youth among older children aged 8 and 9 years [23] . however, other studies have shown that boys' emotion regulation and behavior are more susceptible to parenting behavior than girls [26, 27] . previous research has focused on how different parenting practices are associated with increased or decreased screen time in young children [28] . however, there is little information on whether parenting may moderate the association between screen time and self-regulation. for example, the potential negative influence of screen time on children's self-regulatory abilities may be negated by supportive, positive, and engaging parenting. overall the literature points to some clear risk factors for elements of poor self-regulation, including lower income, maternal mental health, child sex, and screen time. however, how these risk factors might be moderated by childcare and parenting is less clear. the purpose of this study is to identify whether modifiable factors (such as childcare and parenting behavior) moderate known risk factors including lower income, maternal mental health and child sex on child self-regulation. specifically, we hypothesized the negative associations between child self-regulation and both lower income and maternal mental health would be moderated by participation in childcare outside the home. we also hypothesized that the associations between child self-regulation and both child sex and screen time would be moderated by parenting behavior. because overall self-regulation is group childcare (at age 3) is hypothesized to moderate the association between maternal mental health or lower income and self-regulation. parenting behaviors (at age 3) are hypothesized to moderate the association between child sex or screen time and self-regulation. previous research has examined the role of childcare as a moderator between low income and academic achievement, suggesting a potential effect on attention and cognitive skills [11, 21] . however, it is not known if this moderation extends to other elements of self-regulation. the hypothesis is that childcare provides opportunities for children to interact in a structured environment with skilled providers, which facilitates development of emotional regulation and behavioral control. also, there is evidence that childcare can moderate the negative association between maternal mental health and behavioral control, however, the potential moderating role of childcare for overall self-regulation has yet to be examined [17] . parenting is thought to influence self-regulation through a modeling, interaction, and the emotional environment in the home [22] . parenting behaviors such as high levels of negative reinforcement and low levels of positive interaction are consistently associated with lower emotion regulation and greater behavioral challenges both in cross-sectional and longitudinal studies of children [23] [24] [25] . thus, it is possible that parenting practices may play a role in attenuating or exacerbating the association between male sex or screen time and children's self-regulation. in terms of parenting moderating the association between child sex and self-regulation, data from the longitudinal study of australian children found that harsh parenting did not moderate this association at ages 2 and 3 years [25] . similar results were found from the national longitudinal survey of youth among older children aged 8 and 9 years [23] . however, other studies have shown that boys' emotion regulation and behavior are more susceptible to parenting behavior than girls [26, 27] . previous research has focused on how different parenting practices are associated with increased or decreased screen time in young children [28] . however, there is little information on whether parenting may moderate the association between screen time and self-regulation. for example, the potential negative influence of screen time on children's self-regulatory abilities may be negated by supportive, positive, and engaging parenting. overall the literature points to some clear risk factors for elements of poor self-regulation, including lower income, maternal mental health, child sex, and screen time. however, how these risk factors might be moderated by childcare and parenting is less clear. the purpose of this study is to identify whether modifiable factors (such as childcare and parenting behavior) moderate known risk factors including lower income, maternal mental health and child sex on child self-regulation. specifically, we hypothesized the negative associations between child self-regulation and both lower income and maternal mental health would be moderated by participation in childcare outside the home. we also hypothesized that the associations between child self-regulation and both child sex and screen time would be moderated by parenting behavior. because overall self-regulation is comprised of emotional, behavioral and attention elements, a secondary purpose was to understand the above associations on any or all elements of self-regulation. this study is a secondary data analysis using data from mothers and children participating in the all our families longitudinal pregnancy cohort (formerly all our babies) [29] . briefly, women who were less than 25 weeks gestation, at least 18 years of age, accessing prenatal care in calgary, and able to complete a questionnaire in english were recruited between may 2008 and may 2011. questionnaires were given out twice during pregnancy, at 4 months postpartum, and at 1, 2, 3, and 5 years. response rates varied between 69% and 99% depending on data wave and eligibility to participate in that time period [29] . the current study focuses on self-regulation in children at age 5. because we were interested in predictors of self-regulation among typically developing children, those with a diagnosed developmental delay (autism, cerebral palsy, etc.) were excluded (n = 26). for the current analysis, we included women who responded to both the three-year and five-year questionnaire (completed in 2015 and 2017; n = 1688), which is a composite response rate of 60% of 2819 eligible participants. we excluded 18 participants with incomplete information on the outcome variable, resulting in a final sample of 1644. see supplementary material figure s1 for study flow chart. this study received ethical approval from the university of calgary conjoint health research ethics board. all subjects gave their informed consent for inclusion before they participated in the study. our study received ethical approval from the conjoint health research ethics board of the university of calgary reb13-0868. the outcome measure was self-regulation skills at age 5, which was measured by parent report on the behavior assessment system for children (basc-2). the basc-2 is a comprehensive behavioral assessment including 134 questions which are summarized into 23 scales. parents rate frequency of behaviors and raw scores are converted to t-scores with mean = 50, standard deviation (sd) = 10. scores between 60 and 69 are considered "at risk" and scores of 70 are "clinically significant". consistent with the theoretical literature, we operationalized poor self-regulation as children who scored "at risk" or above on one or more of the inattention, emotional control, or executive function scales. the inattention scale covered concepts about listening and focusing attention. the emotional control scale included concepts such as losing one's temper and quick mood changes. the executive function scale included a high number of behavior control items such as hitting other children or waiting one's turn. the basc-2 is appropriate for use in the general population, has strong psychometric properties, and the scales correspond to the theoretical literature on how to measure self-regulation [4, 8] . risk factors included income, maternal mental health, child sex, screen time, childcare, and parenting, and were measured at age 3. income was self-reported household income. maternal depression was measured using the 20-item center for epidemiology studies-depression (ces-d) scale. a score of 16 or more is considered clinically relevant and cronbach's alpha in this sample was 0.89 [30] . maternal anxiety was measured using the 20 item speilberger state anxiety scale (ssai). a score of 40 or more considered clinically significant, and cronbach's alpha is this sample was 0.93 [31] . child sex was reported by mothers at birth. screen time was measured by maternal report of how much time they estimated their child spent watching television, movies, or playing videogames per day. responses ranged from less than 1 h to over 5 h and were dichotomized according to national guidelines for this age group (1 h or less compared to more than 1 h per day) [32] . children were considered to be in childcare if they spent more than 10 h a week outside the home in a group-based childcare [21] . parenting was measured using the national longitudinal study of children and youth (nlscy) parenting scales which measure positive parenting (praise and support) and hostile/ineffective parenting (anger and repeated commands). scales showed adequate internal consistency with cronbach's alphas for each scale of 0.75. because parenting scales have no validated cut-offs, we used a 1 standard deviation cut-off to indicate low levels of positive parenting and high levels of hostile/ineffective parenting. control variables included child age in months and maternal age in years. descriptive statistics were provided for all variables. among the 1644 included participants, there was less than 1% missing data on any given variable, thus we conducted a complete case analysis. to understand the components of self-regulation, the number of children scoring at risk on one or more of the inattention, emotional control, or executive function scales was calculated. the children scoring at risk on one, two, or more of each of the scales was depicted graphically. to assess effect modification, interaction terms were created for the following variables: income and childcare, maternal depression and childcare, maternal anxiety and childcare, parenting and child sex, and parenting and screen time. we developed five models to estimate odds ratios (or) and 95% confidence intervals (ci) between risk factors and self-regulation. model 1 estimated odds of poor self-regulation based on scoring "at risk" on one or more of the scales. model 2 estimated odds of poor self-regulation based on scoring "at risk" on all of the scales. models 3, 4, and 5 estimated odds of poor inattention, emotional control, or behavioral control, respectively. non-significant interaction terms (<0.05) were dropped. all models were adjusted for all other variables in the model as well as maternal age in years and child age in months. a sensitivity analysis was conducted to ensure dichotomization did not result in loss of information by running all predictors with continuous values. a robustness analysis was conducted using 20 h of childcare per week. all analyses were completed using stata v.16. descriptive statistics for participants are presented in table 1 . characteristics of poor self-regulation by constituent elements are shown in figure 2 . of the 1644 children, 354 (21.5%) were at risk on any element of poor self-regulation, and only 64 were at risk for all elements (3.9%). thirteen percent of children were at risk for poor emotional self-control (n = 221), 11.0% were at risk of poor behavior control (n = 181), and 10.9% were at risk of inattention (n = 179). among those at risk on at least one scale (n = 354) approximately 54% of children were only at risk on one scale (n = 191), 28% were at risk on two scales (n = 99), and 18% on all three scales (n = 64). the overlap between children with "at risk" levels of inattention, poor emotional control, or poor behavior control can be seen in figure 2 . adjusted odds ratios for any element, all elements, and each element of poor self-regulation can be seen in table 2 . none of the potential moderators were statistically significant, and therefore are not included in the results. increasing income was associated with decreased odds of poor self-regulation in models 1, 3, and 5. maternal mental health at 3 years (depression or anxiety) had consistently elevated point estimates across all models. for models 1, 3, and 5, maternal anxiety at 3 years was associated with increased odds for elements of self-regulation (any, inattention, and behavior control), whereas maternal depression at age 3 was associated with increased odds for being at risk on all elements or on emotional self-control only (models 2 and 4). group childcare did not moderate either of these predictors in any of the models, but was independently associated with increased odds poor self-regulation in model 3 (inattention). male children had increased odds of poor self-regulation across all models, except emotional self-control (model 4). elevated screen time was associated with increased odds of poor self-regulation in model 1 (any element) and model 3 (inattention). neither hostile/ineffective parenting or positive parenting moderated either of these associations. however, high levels of hostile/ineffective parenting were associated with increased odds of poor self-regulation across all models. table s1 with consistent results. in these models, one additional hour of screen time per day is associated with a 1.23 increased odds of any element of poor self-regulation (model 1; 95% ci 1.03, 1.47), and a 1.42 increased odds of inattention (model 3; 95% ci 1.13, 1.79). the robustness analysis increasing the hours in childcare from 10 to 20 per week did not result in any meaningful changes. adjusted odds ratios for any element, all elements, and each element of poor self-regulation can be seen in table 2 . none of the potential moderators were statistically significant, and therefore are not included in the results. increasing income was associated with decreased odds of poor selfregulation in models 1, 3, and 5. maternal mental health at 3 years (depression or anxiety) had consistently elevated point estimates across all models. for models 1, 3, and 5, maternal anxiety at 3 years was associated with increased odds for elements of self-regulation (any, inattention, and aor: adjusted odds ratio-adjusted for all variables in the table and maternal age, maternal education, and child age. ci: confidence interval. original models included the following interaction terms: income*hildcare, maternal anxiety*childcare, maternal depression*childcare, male child*hostile parenting, male child*positive parenting, screen time*hostile parenting, screen time*positive parenting. all interaction terms were dropped because they were not statistically significant (0.05) all statistically significant predictors (at 0.05) are bolded, the * refers to the mathematical symbol for multiplication. our findings revealed that there is considerable overlap between different elements of self-regulation, as measured in the current study, including attention, emotional control, and behavioral control. this is consistent with the theoretical literature [2, 4] and emphasizes that children may have challenges in one or multiple areas, possibly indicating increasing levels of severity of self-regulation challenges. contrary to expectations, neither childcare nor poor parenting moderated the associations between predictors at age 3 (income, maternal mental health, male sex, or screen time) and self-regulation at age 5. maternal mental health (maternal anxiety or depression), male sex, and high levels of ineffective/hostile parenting were consistently associated with elements of poor self-regulation across all models. higher income was generally associated with lower odds of poor self-regulation, whereas participation in childcare and screen time associations varied. consistent with previous studies, our results showed that higher income was associated with decreased odds of poor-self regulation [8, 12, 18] . however, contrary to expectations, participation in childcare did not moderate this association. we posit two possible reasons for this lack of moderation. first, our study measured time in group child care as opposed to quality of child care and quality has been shown to be a better predictor of child outcomes [20] . second, while only 35% of children were in childcare for more than 10 h per week at age 3, by age 5, almost all children were either in group childcare, preschool or kindergarten at least 10 h a week. this may have meant that a possible effect of childcare at age 3 was masked by increasing participation in childcare at the time of the outcome at age 5. our study is consistent with previous studies showing an association between maternal depression and lower emotion regulation in children [14, 15] . our study adds to our understanding of maternal mental health's role by demonstrating a consistent association between maternal anxiety and other elements of self-regulation, including inattention and behavior control. because mental health symptoms often co-occur, it is important to recognize that overall maternal mental health (characterized by either depressive or anxiety symptoms) may be an important predictor of child self-regulation. however different symptoms may operate differently on different aspects of self-regulation with depressive symptoms impacting emotion regulation (model 4) and anxiety symptoms impacting inattention and behavior control (models 3 and 5). there was an unexpected increased odds of inattention at age 5 with participation in childcare at age 3 (model 3) and non-statistically significant elevated odds of childcare influencing behavior control and any or all elements of self-regulation (models 1, 2, and 5). previous work suggests that childcare instability is associate with more hyperactivity and inattention [17] . as noted above, we were not able to account for quality or consistency of childcare which may partially explain this unexpected result. our study adds to the growing literature regarding concerns of excess screen time and child development [33, 34] . our results show a modest, but statistically significant relationship between screen time and problems with any element self-regulation (model 1; adjusted odd ratios (aor): 1.34, 95% ci 1.03, 1.73). this result was consistent whether screen time was categorized according to guidelines (1 h per day), but also showed a dose-response relationship with increasing odds for every additional hour of screen time. our study adds to our understanding of this relationship by showing that the association between screen time and self-regulation is predominantly driven by the association with inattention, as opposed to other elements of self-regulation (aor for inattention: 1.69, 95% ci 1.20, 2.38). although our study did not measure the content of screen time viewing, previous research suggests that entertainment related television content is associated with attentional problems, but not educational content, and that children in this age group are much more likely to watch non-educational content [35] . screen time among children exceeded guidelines before the global covid-19 pandemic, and is expected to increase with physical distancing measures, online learning, and parents working from home [36, 37] . child health advocates caution about increased sedentary behavior and physical health impacts during the pandemic, but more research is needed into possible developmental challenges associated with excess screen time [38] . we found no evidence for moderation of either child sex or screen time by parenting. however, our results are consistent with other cross-sectional studies linking hostile/ineffective parenting as an independent predictor of poor self-regulation [39, 40] . specifically, hostile/ineffective parenting was associated with an adjusted odds ratio of 3.32 (95% ci 2.44, 4.53) of overall poor self-regulation. there was no independent effect of positive parenting on overall poor self-regulation. while the relationship between parenting and child behavior is likely in part bidirectional [41] , our longitudinal results suggest that hostile parenting behaviors as early as age 3 may have harmful effects on the development of self-regulatory skills at age 5. while our study did not control for prior self-regulation, a study by colman et al. noted that parenting practices were still associated with later self-regulation even when controlling for earlier self-regulating skills [23] . our study's strengths include a complex measure of self-regulation as captured by three scales on the basc-2, which reflect the key components of self-regulation including emotional regulation, behavior control, and attention. while direct observation of self-regulation skills by an independent observer would be a gold-standard for measurement, the size of our sample makes direct observation unfeasible. our study had a large sample size and longitudinal design which allowed us to examine risk factors which were measured at a timepoint prior to the outcome. our study also has several limitations. first, we had a high number of non-responders, which resulted in a collective response rate over two waves of data collection at 5 years of 60%. responders were more socioeconomically advantaged (higher income and education) and older than non-responders [29] . this limits the generalizability of our results, and our findings may not be applicable to more disadvantaged groups. as we expect self-regulation challenges to be higher in more disadvantaged groups, this may mean our prevalence of self-regulation skills is underestimated and our associations with predictors to be biased towards the null. however, research from other longitudinal child behavior studies suggests that adjusted analysis minimizes the magnitude of this type of bias [42] . second, measures of maternal mental, parenting, and child behavior were all reported by mothers which could result in reporting bias [43] . however, previous research attempting to quantify reporting bias through multiple observers have found that associations remain after accounting for shared variance [44] . the goal of our study was to assess known risk factors and potential moderators, and we did not attempt to assess potential mediations. future studies could identify potential pathways and mediation mechanism. as our study is a secondary data analysis, we were not able to assess all possible factors. previous research suggests sleep is an important predictor of self-regulation, and future studies should include a measure of sleep [45] . while our findings indicate that multiple factors contribute to the development of self-regulation in early childhood, the most consistent predictors of self-regulation challenges at age 5 were lower income, male sex, and inconsistent/hostile parenting at age 3. we did not find evidence for effect modification in our models. parenting programs based on improving parenting practices that focus on positive relational interactions have been shown to improve child behavior, and can be effective at early ages [46] . with increasing levels of screen time among young children, our findings regarding screen time's negative association with attentional elements of self-regulation warrants additional research. this point is of particular concern among rising screen time due to the covid-19 pandemic. our findings suggest that risk factors for poor self-regulation in children are evident much earlier than school entry and provide an opportunity for early identification of children at risk. the following are available online at http://www.mdpi.com/2227-9067/7/10/186/s1, figure s1 : flow chart for participant enrollment and response 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depression scale for research in the general population test manual for the state-trait anxiety inventory american association of pediatrics. media and young minds screen time use in children under 3 years old: a systematic review of correlates increased screen time: implications for early childhood development and behavior associations between content types of early media exposure and subsequent attentional problems prevalence of preschoolers meeting vs exceeding screen time guidelines screen time for children and adolescents during the covid-19 pandemic applying harm reduction principles to address screen time in young children amidst the covid-19 pandemic child routines and self-regulation serially mediate parenting practices and externalizing problems in preschool children marital hostility, hostile parenting, and child aggression: associations from toddlerhood to school age the effect of toddler emotion regulation on maternal emotion socialization: moderation by toddler gender selective drop-out in longitudinal studies and non-biased prediction of behaviour disorders convergent validity of and bias in maternal reports of child emotion concentrations and sources of cadmium, copper, lead and zinc in house dust in christchurch a developmental cascade model of behavioral sleep problems and emotional and attentional self-regulation across early childhood. behav behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years we wish to thank the contribution, time and effort provided by all the participants in the all our babies/all our families study. we also acknowledge the contribution of the staff, students and trainees of the all our babies/all our families team. the authors declare no conflict of interest. key: cord-321621-maym3iah authors: rogala, anna; szczepaniak, maria; michalak, natalia; andersson, gerhard title: internet-based self-help intervention aimed at increasing social self-efficacy among internal migrants in poland: study protocol for a randomized controlled trial date: 2020-04-23 journal: internet interv doi: 10.1016/j.invent.2020.100322 sha: doc_id: 321621 cord_uid: maym3iah background: migration is a challenging life transition that may be a source of various problems related to well-being and mental health. however, the psychological adaptation of migrants may be potentially facilitated by social self-efficacy—the beliefs in one's ability to initiate and maintain interpersonal relationships. previous research suggests that social self-efficacy is positively related to adjustment and negatively related to loneliness, depression, and psychological distress. research also confirms that self-efficacy beliefs can be effectively enhanced using internet-based interventions. these results served as a background for creating the new in town, a self-help internet-based intervention for internal migrants in poland that aims at increasing social self-efficacy. exercises in the intervention are based on the principles of cognitive behavioral therapy and relate to sources of self-efficacy beliefs: mastery experiences, vicarious experiences, verbal persuasions, and emotional and physiological states. users complete increasingly challenging tasks that encourage them to interact with their environment. the aim of this trial was to investigate the efficacy of the new in town intervention. methods: the efficacy of the new in town intervention will be tested in a two-arm randomized controlled trial with a waitlist control group. social self-efficacy will be the primary outcome. secondary outcomes will include loneliness, perceived social support, and satisfaction with life. additionally, we will measure user experience among participants allocated to the experimental group. we aim to recruit a total of n = 280 participants aged at least 18 years who have changed their place of residence in the last 6 months and have an internet connection. participants will be assessed at baseline, 3-week post-test, and 8-week follow-up. discussion: the trial will provide insights into the efficacy of internet-based self-help interventions in increasing social self-efficacy. given that the intervention works, new in town could provide an easily accessible support option for internal migrants in poland. trial registration: the trial was registered with clinicaltrials.gov (identifier: nct04088487) on 11th september 2019. internet-based self-help intervention aimed at increasing social self-efficacy among internal migrants in poland: study protocol for a randomized controlled trial the number of migrants worldwide has been growing rapidly over the past years [1] . most of them migrate inside their own country [2] . according to the estimations of the united nations development programme, in 2009 there were 740 million internal migrants worldwide, compared to 214 million international migrants [3] . king and skeldon [2] suggest that "the age of migration is therefore also an age of mass internal migration" (p. 1621). migration-both internal and international-is a source of potential specific stressors that could threaten migrants' well-being and mental health, e.g., communication difficulties, cultural differences, socioeconomic as well as employment status change [4] . it is also a challenging life transition that may be related to problems in the social area. research has shown that students and visiting scholars from china in canada report more communication problems, difficulties in making friendships, loneliness, and lower subjective adaptation, compared to non-chinese canadian and chinese-canadian students [5] . research also suggests that depression symptoms are more prevalent among internal migrants in china compared to the general population [6] . what is more, internal migrant adolescents report lower levels of self-esteem, higher levels of depression, and have less social connections than local adolescents [7] . however, psychological adaptation of migrants may be facilitated by personal resources, such as self-efficacy beliefs [8] . social cognitive theory [9] defines selfefficacy as ''belief in one's capabilities to organize and execute the course of action required to produce given attainments''(p. 3). self-efficacy has been shown to be one of the important factors that help an individual to deal with stressful life transitions and adjust to a new situation [8] . maciejewski, prigerson, and mazure [10] found that self-efficacy mediates the j o u r n a l p r e -p r o o f 4 relationship between dependent stressful life events and symptoms of depression among americans with a prior history of depression. moving to a new residence (internal migration) was the most often reported life event in the aforementioned study (n = 314), along with serious financial problems (n = 216) and life-threatening illness or injury (n =101) [10] . jerusalem and mittag [8] suggested that "within this stressful transitional adaptation to the new societal living conditions, self-efficacy can function as a personal resource protecting against deleterious experiences, negative emotions, and health impairment" (p. 179). numerous studies have confirmed the positive effects of self-efficacy beliefs among migrants. research on young east german migrants suggests that individuals high in selfefficacy perceive changes in their lives more as challenges and less as threats, and report lower anxiety and better health than migrants low in self-efficacy [8] . american expatriates in europe with high levels of self-efficacy express greater degrees of cultural adjustment than those with low levels [11] . wang and sangalang [12] found that among filipino immigrant employees in canada self-efficacy is positively related to work adjustment. a study among afghan and kurdish refugees in new zealand and australia showed that self-efficacy beliefs were associated with higher subjective well-being and lower psychological distress [13] . selfefficacy was also found to be a predictor of mental health among malawian returning refugees [14] . moreover, research among somali adolescents resettled in the united states suggests that self-efficacy is positively related to a sense of school belonging and negatively to ptsd and depression symptoms [15] . not only self-efficacy beliefs but also social support from friends and significant others is positively related to psychological adjustment [16] and subjective well-being of migrants [17] . therefore, the constitution of a new social network is very important for this population. there is one type of self-efficacy beliefs that may especially help migrants to establish new social bonds-social self-efficacy [18] . although self-efficacy can be defined j o u r n a l p r e -p r o o f 5 [8] more globally as a "traitlike general sense of confidence in one's own capabilities to master different types of environmental demands" (p. 177), it is usually conceptualized as a context-specific construct [9] [19] . research suggests that using domain-specific self-efficacy measures allows predicting the outcomes more successfully [20] . social self-efficacy beliefs can be defined as [21] "confidence in one's ability to engage in the social interactional tasks necessary to initiate and maintain interpersonal relationships in social life and career activities" (p. 98). research has shown that social self-efficacy is negatively correlated with attachment anxiety, depression, and loneliness among internal migrants in the usafreshman college students [22] . in addition, social self-efficacy mediates the relationship between attachment anxiety and loneliness [22] . social self-efficacy is also negatively related to acculturative stress, depression, and self-concealment among international college students in the united states [23] . fan and mak [24] found that first-generation migrant students in australia reported lower social self-efficacy than second-generation ones. they also reported more social difficulties and fewer shared interests with people in the host society, compared to second-generation migrant students [24] . international students in canada also reported lower levels of social self-efficacy than canadian and secondgeneration migrant students. moreover, their low self-efficacy predicted low academic satisfaction and high psychological distress [25] . similar results were obtained in australia-chinese migrant and overseas students reported lower self-efficacy than anglo-australian and second-generation migrant students from southern europe. social self-efficacy was also positively related to academic satisfaction and negatively to psychological distress. overall, the results of the aforementioned study suggest that social relationship issues impact the academic satisfaction of overseas students and migrants to a greater extent than the satisfaction of non-migrant students [26] . therefore, it may be concluded that social selfefficacy is potentially beneficial for the psychological adjustment of migrants helping them j o u r n a l p r e -p r o o f 6 establish new connections in the social environment. however, most evidence for the positive effects of social self-efficacy is derived from non-experimental research. our study addresses this gap. not only social self-efficacy, but also other factors, such as age, gender, educational level, and occupational background, socio-economic position, and availability of social support are related to adjustment and well-being of migrants [27] [28] . however, not all of these factors can be easily changed. on the other hand, self-efficacy beliefs in various domains, including initiating and maintaining interpersonal relationships, are malleable and can be intentionally enhanced [29] . in line with bandura's social cognitive theory [9] , selfefficacy beliefs can be altered by interpreting information from four different sources. first, perceived as the most powerful is mastery experience rooted in the interpretation of one's own performance in a specific domain as successful. second, the vicarious experience is related to observing the accomplishments of others which can be interpreted as a proof of specific goals attainability. encouraging feedback about one's own skills, abilities or performance given by significant others serve as a third source of self-efficacy beliefs, verbal and social persuasion. psychological and emotional states are the fourth source. individuals treat their emotional and physiological reactions like stress or anxiety while performing particular tasks as indicators of their capabilities [9] . bandura's theoretical framework found support in empirical research results [30] [21] . therefore, we can distinguish not only theoretically but also empirically the aforementioned sources in the context of social selfefficacy beliefs [21] . furthermore, previous research showed that an internet-based intervention drawn upon social cognitive theory could be an effective means of self-efficacy beliefs reinforcement [31] . human services professionals exposed to indirect trauma who took part in an internet-based intervention displayed significantly greater improvements in self-j o u r n a l p r e -p r o o f efficacy beliefs related to managing secondary traumatic stress compared to an active control group. the internet-based sessions included modules focused on recalling past personal successes, the cognitive reappraisal of situations perceived as failures, an individually tailored plan of boosting self-efficacy beliefs and positive thoughts, and emotions reinforcement [31] . internet-based interventions are a promising approach to reinforcing the self-efficacy of participants in a variety of specific contexts. teachers who accomplished an internet-based problem-solving training displayed significantly greater improvements in general and work-specific self-efficacy compared to waitlist control group members [32] . an online positive psychology intervention to promote positive emotions, self-efficacy, and engagement at work consisting of modules targeting happiness, goal setting, and resource building, has shown its positive impact on participants' self-efficacy [33] . the web-based intervention aimed at promoting healthy eating has proven its effectiveness in enhancing selfefficacy for total dairy intake among college students [34] . moreover, the internet-based program aimed at reducing cannabis use has shown a positive effect on participants' userelated self-efficacy [35] . to sum up, empirical evidence suggests that self-efficacy beliefs are malleable and can be effectively enhanced using internet-based interventions [31] [32][34] [35] .the aim of this study will be to evaluate the efficacy of a newly developed self-help internet-based intervention, new in town, in enhancing social self-efficacy when internet-based interventions by encompassing theory-driven content. we expect that an experimental intervention group will be superior to the control group regarding primary outcome-social self-efficacy-and secondary outcomes such as loneliness, perceived social support, and satisfaction with life. furthermore, we will evaluate the user experience of the intervention. the study is a two-arm randomized controlled trial in parallel design. participants will be randomized into two groups: a self-help internet-based intervention (new in town) and a waiting list control group. the trial was registered at clinicaltrials.gov (identifier: nct04088487) on 11 st september 2019. the study protocol and informed consent have been approved on 15 th january 2019 by the ethics committee of the faculty of psychology at the swps university of social sciences and humanities in warsaw, poland (ref. no. 4/2019). the new in town is an internet-based intervention created by the researchers at the swps university of social sciences and humanities in warsaw. it is available in the polish language version. the mode of internet recruitment and data collection enables potential participants from all over poland to apply for trial enrollment. months. targeted sample is prone to adjustment disorders development. in line with dsm-v, adjustment disorder became chronic when the symptoms persist more than six months from the moment when the trigger has occurred [38] . as the new in town intervention is focused on soft skills development related to social self-efficacy it cannot be treated as professional help for those individuals who faced clinical symptoms of chronic adjustment disorder. therefore, we have chosen the criterion of 6 months. when explaining participants this criterion we use internal migration definition of statistics poland-"change of place of residence (…) in the territory of poland, related to crossing the administrative border of a gmina (polish administrative unit), including-in case of urban-rural gminas-changes of the place of residence within a gmina, i.e. from rural to urban areas and vice versa" [39] . the exclusion criterion is the lack of internet access. applicants who meet inclusion criteria will be automatically directed to electronic informed consent to enroll in the study. all study j o u r n a l p r e -p r o o f 10 participants will be informed of their right to delist from the study without any consequences. after giving consent, participants will be asked to complete baseline questionnaires. the intervention aims at increasing social self-efficacy and consists of cognitive behavioral therapy (cbt)-based exercises related to sources of self-efficacy beliefs: 1) mastery experiences, 2) vicarious experiences, 3) verbal persuasions, and 4) emotional and physiological states [9] . intervention contains 8 modules (see table 1 ). users complete increasingly challenging tasks that encourage them to interact with their environment. psychoeducation on social support (e.g. buddy support exercise). psychoeducation on emotional and physiological states as a source of self-efficacy beliefs (e.g. self-care exercise). planning initiating and maintaining interpersonal relationships (e.g. goal setting exercise). all data including informed consent will be stored in cloud-based software, surveymonkey. this platform uses an encrypted connection, which guarantees the security of data transmission. assessments will not require any personal data, except an email address. it is necessary in order to send an online questionnaire link at post-test and follow-up. only authorized persons will have access to the stored data. the sample size will be determined a priori using g*power [40] . empirical evidence suggests a medium effect of internet-based interventions aimed at increasing self-efficacy beliefs [31] . in our analysis we will include four outcomes. therefore, we will apply bonferroni's adjustment that will compensate for multiple comparisons and lower the probability level. [41] . therefore, we plan to include 280 participants at baseline (140 participants per condition). after completion of the informed consent and baseline questionnaires, all participants will be randomized and assigned with a 1:1 ratio to one of two groups. information about group allocation will be provided within 2 days to participants. blinding allocation is not possible due to the study design. participants assigned to the new in town group will be provided with login details as soon as possible. the waiting-list group will be given login instruction 8 weeks after baseline. both groups receive access to the intervention for a period of 3 weeks. in order to log in to the intervention website, all participants will get a unique password. after logging for the first time each participant is automatically asked to create own password. the participants can change the password to an account any time they wish. the post-test assessment is scheduled at 3 weeks after baseline, follow-up assessment at 8 weeks after baseline. all assessments (baseline, post-test, and follow-up) are self-reports and will be conducted online. research has confirmed the reliability and validity of the internet administration format of self-report psychological questionnaires [42] . participants will be informed via email to complete assessments and will receive links to online questionnaires. two email reminders will be sent if the questionnaires stay incomplete for one week. eligible participants will be randomized by an independent researcher after the baseline measurement to either an experimental group or a waitlist control group (1:1 allocation ratio) using an online randomization program (www.randomizer.org). to ensure an equal number of participants in both study conditions we will use non-stratified block randomization with two participants per block. all outcomes will be measured in each assessment; baseline, post-test (3 weeks after baseline), and follow-up (8 weeks after baseline). exceptions are demographic data and user experience. demographic data will be collected at baseline, while user experience will only be assessed at the post-test among participants allocated to the experimental group. in a feasibility study, the reliability of measures was acceptable, with cronbach's alpha ranging from .58 to .96. the average completion time of online questionnaires was 18 minutes. general self-efficacy scale. social self-efficacy is the primary outcome studied. it will be measured with the general self-efficacy scale (gses) [18] . the gses consists of two subscales for measuring 1) generalized beliefs about self-efficacy (17 test items) and 2) beliefs about self-efficacy in establishing and maintaining relationships with others (6 test items). the remaining test items (7) are buffer theorems. the respondents give answers on a scale 5-point likert scale (1 = strongly disagree, 5 = strongly agree). in the trial, we will use one subscale, which measures beliefs about self-efficacy in establishing and maintaining relationships with others. social self-efficacy will be indicated by the total sum of 6 items scores, e.g. "i have acquired my friends through my personal abilities at making friends". j o u r n a l p r e -p r o o f higher scores reflect a higher level of self-efficacy. the scale demonstrates good psychometric properties [18] . de jong gierveld loneliness scale [43] will be used to measure loneliness. the scale is composed of 11 items; 6 of them are formulated negatively and 5 positively. each item is measured using on 5-point likert scale (1 = definitely yes, 5 = definitely no), e.g. "i often feel rejected". positive items should be reversed. the sum of scores is counted on 2 separate subscales: emotional and social loneliness. the scale can be applied in different data collection modes; in face-to-face interviews as well as in online questionnaires. it is a wellvalidated measure with a bifactor structure [44] . the berlin social support scale (bsss) [45] will be used to assess social support. the bsss consists of 6 subscales: perceived available support, need for support, support seeking, actually received support (recipient), provided support (provider), protective buffering scale. the scale contains 32 items that are scored on a 4-point scale (1 = strongly disagree, 4 = strongly agree). before scoring items, negative ones need to be reversed, e.g. "i get along best without any outside help". scores can be counted either on a general scale or subscales. the measure was validated in several studies and showed good reliability [45] [46] . in the trial, only 3 of 6 subscales will be applied: perceived available support (8 test items), need for support (4 test items), and support seeking (5 test items). internal consistency and test-retest reliability are highly satisfactory [49] . swls is widely used to measure satisfaction understood as a component of well-being [50] . demographic data questionnaire. this short questionnaire contains questions about gender, age, education, profession, tenure, the old and the new place of residence (rural area, city up to 20,000 residents, city up to 100, 000 residents, city up to 500, 000 residents, city with more than 500,000 residents) questionnaire. an overall impression of the intervention will be assessed by the user experience questionnaire (ueq) [51] . it is a self-reported measure that contains 6 subscales: attractiveness, perspicuity, efficiency, dependability, stimulation, novelty. participants respond to 26 items (e.g. annoying/enjoyable) using a 7-point scale (-3 = the most negative answer, 0 = neutral, +3 = the most positive answer). the ueq presents high internal consistency and good validity of scales [51] . generalized estimating equations (gee) approach will be used to examine changes in primary and secondary outcomes over time and to assess differences between experimental and waitlist control group. this approach allows the correlated structure of data from repeated measures. what is more, gee is nonparametric and does not assume that the dependent variable is normally distributed [52] [53] [54] . we will include group (experimental/waitlist control), measurement time and interaction between group and time as independent variables. dependent variables will include social self-efficacy, loneliness, perceived social support, and satisfaction with life. qic coefficients will be used to choose the best assumption for the working correlation matrix. we will follow intention-to-treat j o u r n a l p r e -p r o o f 17 (itt) principles and use model-based imputation to handle missing values [55] . adverse events will be assessed through the categorization of primary outcome change. we will recognize change that: 1) is higher than -30% from baseline as deterioration events, 2) is between -30% to 30% from baseline as non-response events, 3) is between 30-50% from baseline as minimal response events, and 4) is higher than 50% from baseline as remission events. this classification scheme will enable us to compare outcomes, such as worsening with improving symptoms or non-response to intervention [56] [57]. to assess possible measurement bias we will compare the outcome change with and without the effect of missing data. all analyses will use intention-to-treat (itt) principles. we will additionally perform per-protocol analyses to examine the robustness of the effects. individual characteristics of participants can become confounding variables. random assignment to groups minimizes the potential for confounding. nevertheless, to assess possible assignment bias we will compare demographic and baseline characteristics between experimental and waitlist control group. the choice of sensitivity analyses will be, therefore, to some extent, data-driven [58] . migrants go through a stressful process of transition and adaptation which may be related to problems in the area of well-being and mental health [4] . however, research suggests that adaptation of migrants may be facilitated by social self-efficacy beliefs [ evidence also suggests that self-efficacy is malleable and can be effectively reinforced using internet-based interventions [31] [32][34] [35] . because the number of migrants is steadily increasing over the past years [1] and more than 30% of polish citizens are internal migrants [36] , the current challenge is to develop an effective and easily accessible intervention targeting this population. with our study, we hope to gain insight into the efficacy and acceptance of the new in town-self-help internet-based intervention aimed at increasing j o u r n a l p r e -p r o o f social self-efficacy among internal migrants in poland. the study is a randomized controlled trial with a waitlist control group. the primary outcome is social self-efficacy. secondary outcomes include loneliness, satisfaction with life and perceived social support. we will also explore user experiences. the study is not free from limitations. firstly, the online platform does not collect the data of the way participants will use the intervention (duration and frequency of being logged in to it). it is crucial to explore participants' patterns of accomplishing modules and identify the most crucial modules. each intervention module is activated one by one, but participants have always the possibility to return to previous ones. dates of module activation are not set in advance. therefore, the chance that some participants might complete the whole intervention at once still exists. on the other hand, open access to non-blocked modules allows participants to use the intervention at own pace and to adapt exercise completion to the daily life duties. at the post-test, we plan to collect user experience data that might be helpful in enhancing the intervention. secondly, the new in town and assessments were not provided on the same platform. this inconvenience may have an impact on drop-out rates. relatively high dropout rates are found in a number of internet-based interventions studies [59] [60] . therefore, we plan to adjust for missing data using the gee approach [53] . the other concern is recruitment. participants will be recruited via social and traditional media campaigns. it will be a self-selected sample that might be highly motivated for internet-based interventions. this fact could affect the outcomes and become the main concern that should not be ignored without considering further research directions. for this reason, we plan in the near future to transfer the intervention to a more traditional medium and conduct it in the form of workshops or e-learning courses dedicated to freshman college students and assess its efficacy as well. moreover, the control group in our study is a waitlist control. research has shown that using this type of control condition may lead to bigger j o u r n a l p r e -p r o o f treatment effect sizes estimates compared to no treatment and psychological placebo [61] . however, the aforementioned research was on cbt for depression and therefore generalizability of this evidence may be limited. additionally, one of the inclusion criteria is having changed the place of residence in the last 6 months. therefore, participants in a waitlist control group can wait longer to access the intervention than they were between changing the place of residence and study enrolment. because of that study could yield more conservative results. future studies should focus on comparing the new in town with a different intervention as an active control condition. there will also be several strengths of this study. firstly, the content of the new in town intervention is theory-driven. exercises in the intervention are based on the principles of cognitive behavioral therapy and relate to four sources of self-efficacy beliefs. according to social cognitive theory, these beliefs can be enhanced by interpreting information from mastery experiences, vicarious experiences, verbal persuasions, and emotional and physiological states [9] . secondly, we will use well-validated measures of primary and secondary outcomes. the strong aspect of the study design is also using two follow-up measurement points that enable us to track long-term effects. finally, the new in town is designed specifically for migrants, who are potentially at greater risk of difficulties in the social area [4] [5] . mind the gap!" integrating approaches to internal and international migration overcoming barriers: human mobility and development common mental health problems in immigrants and refugees: general approach in primary care psychological adaptation of chinese sojourners in canada jin li xm. depression and associated factors in internal migrant workers in china the effects of social connections on self-rated physical and mental health among internal migrant and local adolescents in self-efficacy in stressful life transitions self-efficacy: the exercise of control self-efficacy as a mediator between stressful life events and depressive symptoms differences based on history of prior depression the relationship between cross-cultural adjustment and the personality variables of self-efficacy and self-monitorin work adjustment and job satisfaction of filipino immigrant employees in canada learning to fit in : an exploratory study of general perceived self efficacy in learning to fit in : an exploratory study of general perceived self efficacy in selected refugee groups returning refugees : psychosocial problems and mediators of mental health among malawian returnees belonging and connection to school in resettlement : young refugees , school belonging , and psychosocial adjustment self-efficacy, perceived social support, and psychological adjustment in international undergraduate students in a public higher education institution in malaysia negative affect in east german migrants: longitudinal effects of unemployment and social support the selfefficacy scale: construction and validation guide for constructing self-efficacy scales self-efficacy specificity and burnout among information technology workers: an extension of the job demand-control model sources of social self-efficacy expectations : their measurement and relation to career development adult attachment , social self-efficacy , self-disclosure , loneliness , and subsequent depression for freshman college students : a longitudinal study acculturative stress, and depression in african, asian, and latin american international college students.pdf measuring social self-efficacy in a culturally diverse student population c the psychological adaptation of international and migrant students in canada the psychological adaptation of overseas and migrant students in australia migration, social mobility and common mental disorders: critical review of the literature and meta-analysis. ethn health migration and mental health self-efficacy: a theoretical analysis of its determinants and malleability sources of self-efficacy in school: critical review of the literature and future directions effects of internet-based self-efficacy intervention on secondary traumatic stress and secondary posttraumatic growth among health and human services professionals exposed to indirect trauma efficacy of an internet-based problem-solving training for teachers: results of a randomized controlled trial flourishing students: a longitudinal study on positive emotions, personal resources, and study engagement web-based nutrition education intervention improves self-efficacy and self-regulation related to increased dairy intake in college students a controlled trial of an internet-based intervention the national census of population and housing 2011. 2011. 37. who. who announces covid-19 outbreak a pandemic american psychiatric association. diagnostic and statistical manual of mental disorders. american psychiatric association terms used in official statistics power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences self-guided psychological treatment for depressive symptoms: a meta-analysis public library of science computers in human behavior internet administration of self-report measures commonly used in research on social anxiety disorder : a psychometric evaluation manual of the loneliness scale validating the polish adaptation of the 11-item de jong gierveld loneliness scale soziale unterstützung bei der krankheitsbewältigung: die berliner social support skalen (bsss) long-term effects of spousal support on coping with cancer after surgery the satisfaction with life scale is the shift in chronotype associated with an alteration in well-being ? the satisfaction with life scale and the emerging construct of life satisfaction further validation of the satisfaction with life scale: evidence for the cross-method convergence of well-being measures construction and evaluation of a user experience questionnaire longitudinal data analysis using generalized linear models to gee or not to gee: comparing population average and mixed models for estimating the associations between neighborhood risk factors and health an overview of longitudinal data analysis methods for neurological research dealing with missing outcome data in randomized trials and observational studies measurement of symptom change following web-based psychotherapy: statistical characteristics and analytical methods for measuring and interpreting change a comparison of the characteristics and treatment outcomes of migrant and australian-born users of a national digital mental health service a tutorial on sensitivity analyses in clinical trials: the what, why, when and how adherence in internet interventions for anxiety and depression dropout from internet-based treatment for psychological disorders waiting list may be a nocebo condition in psychotherapy trials: a contribution from network we thank aleksandra bis for contributing to the pilot study. key: cord-329312-bvnky9yr authors: alemany-arrebola, inmaculada; rojas-ruiz, gloria; granda-vera, juan; mingorance-estrada, ángel custodio title: influence of covid-19 on the perception of academic self-efficacy, state anxiety, and trait anxiety in college students date: 2020-10-09 journal: front psychol doi: 10.3389/fpsyg.2020.570017 sha: doc_id: 329312 cord_uid: bvnky9yr the worldwide pandemic situation caused by coronavirus disease 2019 (covid-19) has led to a state of confinement of the population, which has caused, following consulted research, an increase in stress. faced with this situation, the spanish university not only had to adapt to the changes derived from the causes of the pandemic but also had to face a new methodological model—e-learning teaching—for which not all teachers and students were prepared. this could cause an increase in stress due to the uncertainty caused by this time of change. this research analyzes the relationship between perceived self-efficacy in the confinement period and the level of trait anxiety (ta) and state anxiety (sa) during covid-19. four hundred twenty-seven students from the university of granada (spain) participated in this study. the adaptation of two scales that measure perceived academic self-efficacy and anxiety (ta and sa) has been applied. the results indicated that there was an inversely proportional relationship between anxiety and self-efficacy; men showed the highest perception of self-efficacy, while women had higher scores in ta and sa; the latter was accentuated in cases when a relative died. to conclude, students who show a higher level of anxiety (ta and sa) express more negative emotions and also perceive themselves with less academic self-efficacy. therefore, a stressful situation (pandemic and confinement) together with a critical event (illness and death of a relative/friend due to covid-19) increases anxiety levels and influences the perception of academic self-efficacy. march 2020 in spain, the first period of the state of alarm caused by coronavirus disease 2019 was declared. this led to the confinement of the population. among the containment measures adopted in the university field was the suspension of face-toface educational activity. as a result, a more online-focused delivery of education was considered. this change affected more than 89.4% of higher education institutions in european countries, argentina, and russia (marinoni et al., 2020) . garcía-peñalvo (2020) indicated that, although the digitization of the spanish university began a decade ago, we have focused on face-to-face teaching. however, in this time of isolation, it is necessary to integrate technology into classrooms (mingorance et al., 2019) . but any change generated many uncertainties in the university context. thus, not attending faceto-face lessons made the american students worried, nervous, and anxious; therefore, 75% of them would like to go back to face-to-face interactions (kelly, 2020) . confinement, fear of the unknown, and all these changes caused by the health situation of covid-19 have increased negative emotions in the peruvian population, which might harm mental health (huarcaya-victoria, 2020) . according to ozamiz et al. (2020) , in their research within the spanish population, at the moment, it is difficult to know the psychological and emotional consequences of this situation, but it is evident that they can lead to anxiety disorders, depression, stress, and increased consumption of harmful substances (asmundson and taylor, 2020; ozamiz et al., 2020; shigemura et al., 2020; torales et al., 2020; valiente et al., 2020; wang c. et al., 2020) . other investigations delved into the effects of infectious diseases, such as the research carried out by digiovanni et al. (2004) about the severe acute respiratory syndrome (sars) virus in toronto, li et al. (2011) about the h1n1 virus or influenza a in chinese university students, taylor et al. (2008) about equine influenza in the australian population, and tucci et al. (2017) about the ebola virus in occidental africa and the zika virus in brazil and puerto rico. they concluded that, during this pandemic situation, the risk of psychological problems increased in the population. due to the nature of the virus and the fact that is very contagious, among other reasons, the general chinese population experienced these situations with an increase in anxiety, depression, and other stress reactions , incrementing psychological anguish if there was a loss of a relative (mohammed et al., 2015; ho et al., 2020) , results obtained in chinese and nigerian populations. the university environment is not exempt from all these factors. focusing on the science, technology, engineering and mathematics (stem) student body in the united states, these new circumstances originating from covid-19 was joined to the many demanding aspects of this educational stage, such as academic success (hall and sverdlik, 2016) . azad et al. (2017) and the american college health association (2019) reported that, faced with the pandemic situation, turkish and american university students, respectively, had a high risk of suffering anxiety, depression, and panic attacks; these were the most common disorders. in addition, having someone close diagnosed with covid-19 increased the risk of higher anxiety levels in chinese population . furthermore, the university context is potentially stressful, and the situation generated by covid-19 could have a negative impact on students. although there is little research that analyzes the impact of the pandemic on chinese students and its influence on academic expectations, some studies concluded that 21.3% of medicine students showed mild anxiety, 2.7% moderate anxiety, and 0.9% severe levels of anxiety. having relatives or acquaintances infected with covid-19 was a risk factor . in the survey to college students conducted by the american college health association (2019), data indicated that 26% of college students reported feeling very depressed compared to 43% who indicated that they were overwhelmed by anxiety. but in addition, the situation of isolation increased psychological pressure (xiao, 2020) ; the symptoms persisted even after the confinement (pfefferbaum and north, 2020) . regarding the psychological impact, li et al. (2020) reported that 28.8% of the chinese respondents suffered anxiety symptoms from moderate to severe and 8.1% responded that they had stress levels (from moderate to severe); chinese and canadian women suffered from higher levels of stress, anxiety, and depression taylor et al., 2020) . in the same line, vera-villaroel (2020) indicated that the stress generated by the global pandemic was related to anxiety, and women presented higher levels than men (gutiérrez-garcía and landeros-velázquez, 2018). during the covid-19 crisis, 7% of the general chinese population suffered symptoms of depression (kang et al., 2020) , increasing anxiety, depression, and outrage (dubey et al., 2020) . furthermore, anxiety is indirectly related to academic performance and directly related to the perception of academic self-efficacy (gutiérrez-garcía and landeros-velázquez, 2018). therefore, 29% of the spanish university students with a high level of stress had low levels of self-efficacy (navarro-mateu et al., 2020) . in this line, anxiety was negatively related to academic selfefficacy (gutiérrez-garcía and landeros-velázquez, 2018) and positively to state anxiety (sa) in nigerian university students (onyeizugbo, 2010) . on the other hand, the perceived academic self-efficacy in the academic environment and the performance of university students are factors that are positively related. this is stated by colom (2012) and ahmadi (2020) who found that iranian students' self-perceptions about their own ability and competence to perform a certain task is significantly associated with academic performance. a subsequent study confirmed the influence that academic self-efficacy and emotions have on the academic success of university students. thus, higher levels of positive emotionality were related to higher levels of success (de la fuente et al., 2019) . at the academic level, academic self-efficacy was related to performance and indirectly influenced academic aspirations (ahmadi, 2020) . in addition, the stress generated by the academic context (overload of tasks, pressure due to work, frequent evaluations, and the pandemic situation, among others) could lower expectations of self-efficacy. thus, 29% of students with high levels of stress showed low levels of self-efficacy, concluding that there is an inversely proportional relationship (navarro-mateu et al., 2020) . these findings highlight the importance of these variables for academic performance since those who had great academic self-efficacy also presented more study and cognitive tools that helped organize themselves better (delgado et al., 2019) . some research indicated that there were no differences between women and men in academic self-efficacy (rivera-heredia et al., 2016; hernández-jácquer, 2018) ; however, narváez-olmedo et al. (2018) concluded that it is men who showed the highest perception of academic self-efficacy. academic self-efficacy is a variable to be considered in the university context, as it indicates students' future goals according to their abilities, such as achievement motivation, access to scholarships, academic performance, or permanence in higher education (borzone, 2017) . but, in this time of confinement, when we have quickly moved from face-to-face teaching to remote emergency teaching (abreu, 2020) , it was important to analyze whether this improvised change could affect the expectations of perceived self-efficacy of university students to achieve academic success, since students were not prepared. there is little research on the impact of the pandemic and its influence on levels of anxiety in university students, and even less related to expectations of academic self-efficacy. for this reason, the objective of this research is to analyze the relationship between perceived self-efficacy and trait anxiety (ta) and sa, during the first moments of covid-19, since it was an exceptional situation to learn how university students responded to critical situations (related to sa). in addition, the situation of uncertainty and ignorance about the disease was high, generating a great concern in the spanish population and, more specifically, in university students, given the challenges they faced with the closure of the university. there were two hypotheses: (1) there is an inversely proportional relationship between academic self-perception and ta and sa; and (2) the students are more sensitive to this situation if they manifest higher ta and also if they or their relatives and friends have suffered from covid-19. the design used in this research was a retrospective or ex post facto study (sharma, 2019) with a cross-sectional design to collect data. the research was carried out in the melilla campus at the university of granada (ugr) (spain). for the selection of the participating sample, a non-probability sampling was used, using the virtual snowball technique (baltar and gorjup, 2012) . the selected sample consisted of 427 university students with an average age of 21.30 years (sd = 3.27), ranging 20 years, minimum age is 18 and maximum age is 41. eighty-four of the participants were men (19.7%), and 342 were women (80.1%). this percentage is a reflection of the feminization of the degrees in nursing and education sciences. a total of 52.3% (n = 227) of participants were enrolled in the faculty of education and sport sciences, 37.6% (n = 160) were enrolled in the faculty of nursing, 3.3% (n = 14) belonged to the faculty of social sciences, and 5.9% (n = 25) studied master's degrees. in addition, 1.6% (n = 7) of the students had suffered/were suffering from covid-19 compared to 98.4% (n = 420) who answered no. in addition, 23.2% (n = 99) students affirmed that a friend or a relative had suffered from covid-19, and of these, 10.8% (n = 46) died of it. the questionnaires were administered online in march. this was the time of greatest uncertainty and when the state of alarm was declared due to covid-19. for this purpose, the delegates of the courses from the faculties of the university of granada at the melilla campus (spain) were contacted via e-mail. the questionnaires were uploaded to the google form application (free access) with instructions on how to complete it. furthermore, students were asked to explicitly consent to participate in this experience willingly and anonymously, following the indications given by the committee on publication ethics (cope). the questionnaire, https://forms.gle/yp9vgwmas7e8b6we7, consisted of three sections: 1. the sociodemographic data section collected information on age, ongoing studies, if he/she suffered/had suffered from covid-19, and if any relative or friend suffered/had suffered from covid-19 and if they had died of this cause. 2. the "adaptation of the specific perceived self-efficacy scale in confinement situations by covid-19 (asps-covid-19)" scale was based on the "academic situations specific perceived self-efficacy scale" by garcía-fernández et al. (2010) , consisting of 10 items, with a 4-point likerttype response format that ranged from 1 (never) to 4 (always). the minimum score was 10 and the maximum was 40, with a reliability of 0.92. the objective was to measure the expectations of self-efficacy in specific situations in the educational context in university students at the time of isolation due to the pandemic. therefore, the text clarification "during the confinement due to covid-19" was added to the items of the original scale, keeping the original answer format, so the higher the score, the greater the perceived academic self-efficacy. 3. the "adaptation of the trait anxiety/state anxiety scale in confinement situations by covid-19 (ata/sa-covid-19)" scale was based on the spanish adaptation of the "state-trait anxiety inventory (stai)" by spielberger et al. (1982) . the scale was composed of 20 items for the trait anxiety subscale (ta) and 20 for the state anxiety subscale (sa). the response formats ranged from 0 (hardly ever) to 3 (almost always). the internal consistency indices were 0.96 and 0.88, respectively. the ata/sa-covid-19 was made up of 54 items, 28 for ta and 26 for sa. the answer had a 4-point likert-scale format that ranged from 1 (not at all) to 4 (very often). the minimum score was 28 for ta and 26 for sa. items were added and repeated in both scales to measure the influence of the pandemic on the emotional and motivational factors that might affect academic goals, such as anger, outrage, boredom, distraction, discouragement, and despondency. positive items scored inversely (ta: 2, 5, 7, 10, and 15; sa: 1, 2, 5, 8, 10, 11, 15, 16, 20, and 27) , so that the higher the score, the higher the anxiety level. statistical software spss 25.0 was used for conducting descriptive analysis of the data, anova test, reliability statistics, and multivariate analysis. statistical significance was set at p < 0.05. effect size was reported with cohen's. table 1 showed the reliability and descriptive analyses of the total score of the different scales used. as it can be observed, the reliability was very high in the three instruments used. in relation to the ta subscale and in the sa subscale of the ata/sa-covid-19, items 1, 5, 6, 13, and 18 and items 19, 21, 22, and 24 were removed, respectively, as the corrected item-total correlation was under 0.30. the two subscales were composed of 24 items, with a very high inner consistency index, which was measured with the cronbach's alpha. in relation to the first hypothesis, the relationship between asps-covid19 and the ata/sa-covid-19 subscales was analyzed. the pearson's correlation coefficients indicated moderate and significant (p < 0.001) relationships between the scales ( table 2) , thus increasing anxiety-reduced perceived academic self-efficacy. furthermore, in relation to the asps-covid-19 scale, students were classified into three groups: low perception of academic self-efficacy (means below the 20th percentile, x ≤ 16), moderate level of self-efficacy (means between the 21st percentile to the 79th percentile,x ≥ 17.00 tox ≤ 26.00), and high level of academic self-efficacy (x ≥ 27.00). the data showed that the students with the lowest levels of self-efficacy were 99 (23.2%), of which 42 (42.4%) presented very high levels of both ta and sa; 39 women and three men presented the highest level of sa. in addition, one student had suffered from the disease, 19 had a relative who had suffered from it, of whom five had died from covid-19. the inferential analysis based on the sex variable showed significant differences. women showed lower levels of selfefficacy than men (x men = 14.73;x women = 12.91; t = 3,295; p < 0.005; dcohen = 0.717; r sizeeffect = 0.337). the size effect was large. regarding whether any relative had died, data indicated that the students who had lost a relative scored lower in the perception of academic self-efficacy (x yes deceased = 11.69; x nodeceased = 13.52; t = −2.243; p < 0.05; d cohen = −0.708; r sizeeffect = 0.334). the size effect was large. multivariate inferential analyses, using sa and ta as covariates and their influence on perceived self-efficacy, showed significant differences (f 2,426 = 7.57, p < 0.000; ηp2parcial = 0.035), which indicated that the higher the levels of ta and sa, the worse the perception of self-efficacy in academic performance. regarding the second hypothesis, firstly, in the ta and sa subscales, students were classified into three groups in such a way that the first group, with a low level of anxiety, was the one that obtained average scores below the 20th percentile. the group with moderate anxiety level ranged from the 21st to the 79th percentile. last, the third group, with high anxiety levels, obtained means over the 80th percentile. these were the criteria for the three scales. in table 3 , students are presented according to their level of ta and sa. in addition, the students who presented high scores on the ta scale were selected (pc80x ≥ 76). they were a total of 89 (21.07% of the total sample). in this group, nine were men (10.1%) and 80 were women (89.9%), only two university students (one man and one woman) had covid19 (2.2%). furthermore, 39 students had a relative or a friend who had suffered from the disease (43.8%), of whom 11 died (12.4%). of the 89 university students, 79 (88.8%) also showed high levels of sa (pc80x ≥ 77) and 10 (14.6%) moderate levels. sixty-seven were women (83.8%) and nine were men (16.2%); two of them had suffered from the disease. in relation to whether a relative/friend suffered/had suffered from covid-19, 35 answered yes and 12 reported they died of the virus. in the analyses of the students (n = 427), ta and sa showed that the sa was high in this pandemic time during the confinement, the analyzed data showed significant differences, increasing the sa in this pandemic time (ta = 63.74; sa = 66.55; t = −7.212; p < 0.005; d cohen = −0.206; r sizeeffect = −0.102); the size effect was medium. although there were no significant differences, the sa was higher in the students who had a sick frontiers in psychology | www.frontiersin.org relative who died of covid-19 (ta = 63.06; sa = 67.46; t = −1.101; p > 0.05). the results of the students with high levels of sa (n = 109) indicated that a 100% felt worried and nervous, 90.8% felt distressed, and 80% felt helpless in the situation. among the characteristics presented by the students with high levels of ta (n = 126) and in relation to their teachinglearning process, the data indicated that they were unfocused (91.1%), unmotivated (98.8%), and discouraged (100%) in the situation they were experiencing (95%). in relation to how they experienced the confinement, 91% felt angry, 85% outraged, and 80% felt unhappy about the pandemic. the objective of this research is to analyze the relationship between perceived self-efficacy and ta and sa during the first moments of covid-19. with this objective, the "academic situations specific perceived self-efficacy scale" and "state-trait anxiety inventory (stai)" questionnaires were adapted. the reliability found in the asps-covid-19 was similar to that obtained by garcía-fernández et al. (2010) . in the same way, the ata/sa-covid-19 subscales obtained high internal consistency indices similar to fonseca-pedrero et al. (2012) . regarding the first hypothesis, the data showed that there was an inversely proportional relationship between the perception of academic self-efficacy and anxiety, both ta and sa, results in line with the research of gutiérrez-garcía and landeros-velázquez (2018), navarro-mateu et al. (2020), and colom (2012) . one explanation might be that anxiety is related to both cognitive and motivational and emotional processes. in this way, negative emotions such as tension about how students experienced the pandemic and a high level of concern could decrease the levels of achievement and self-efficacy (de la fuente et al., 2019) . but also, university students with high levels of anxiety showed high scores in demotivation, discouragement, and boredom, results in line with the research of vancouver (2018) . these motivational characteristics could negatively affect the expectations of self-efficacy that, together with the demands of the university context, could interfere with their academic aspirations (ahmadi, 2020) . in addition, the psychological pressure of the confinement (xiao, 2020) was joined to the academic demands, workload, and online evaluations that could negatively affect the perception of academic self-efficacy (navarro-mateu et al., 2020) , generating higher levels of anxiety in university students (huarcaya-victoria, 2020 ). in addition, not attending classes due to the closure of universities was a factor of concern and anxiety (kelly, 2020), since the work methodology changed (abreu, 2020) when the students were not prepared. as for the second hypothesis, there was a directly proportional relationship between ta and sa. the students with the highest ta also increased their level of sa during covid-19. this might be due to the fact that the pandemic generated a stressful situation causing highly negative emotions, mainly in students who had someone close diagnosed with covid-19 and those who reported the death of a relative or a friend (mohammed et al., 2015; ho et al., 2020) . thus, the data showed that students with high levels of sa indicated feeling distressed and helpless in this situation, as reported by the american college health association (2019). regarding the analyses of the sex variable, men showed a better perception of self-efficacy, data consistent with those found by narváez-olmedo et al. (2018) . on the other hand, women presented higher levels of anxiety, as reflected by gutiérrez-garcía and landeros-velázquez (2018), cao et al. (2020) , and taylor et al. (2020) . their sa increased in stressful situations, such as the death of a relative (ho et al., 2020) , which directly affected the perception of self-efficacy; this result coincided with gutiérrez-garcía and landeros-velázquez (2018) and de la fuente et al. (2019) who came to the conclusion of the relationship between self-efficacy and emotionality. gender differences in academic self-efficacy could be associated with socialization processes and the perpetuation of gender stereotypes in young university students, learned within a sociocultural context. some limitations must be acknowledged: first, the type of sampling, but given the situation of confinement, it was the only possibility to obtain data. these data were collected at the beginning of the pandemic. the cross-sectional methodology of this study was necessary and mandatory, but it has been compared with other investigations. for future studies, stratified non-probability sampling will be used and the number of participants will be increased. secondly, sa and ta and their relationship with the perception of academic self-efficacy have been analyzed, but it is still necessary to include other complementary instruments, such as effects of changes in learning through academic performance (grades), resilience, selfconcept, and cognitive-motivational factors that might affect the variables studied. it will be necessary to continue working on the adaptation of the instrument used as well. third, we did not analyze the effect of the methodological change and how it affects ta and sa and the perception of academic selfefficacy in the e-learning model, so it should be studied in subsequent investigations. to conclude, students who show a higher level of anxiety (ta and sa) express more negative emotions and also perceive themselves with less academic self-efficacy. therefore, a stressful situation (pandemic and confinement) together with a critical event (illness and death of a relative/friend due to covid-19) increases anxiety levels and influences the perception of academic self-efficacy. thus, students in exceptional situations increase their levels of anxiety and reduce their perception of academic self-efficacy that can put their permanence in higher education at risk. therefore, it is necessary to follow up on university students after confinement in order to explore the causes of anxiety and the influence that covid-19 had on their academic performance and on their permanence in university. the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. 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 for participation was not required for this study in accordance with the national legislation and the institutional requirements. ia-a contributed to the research conception and design, data analysis and interpretation, statistical analysis, and critical revision of the manuscript for important intellectual content. gr-r contributed to obtaining information, reading the manuscript, and critical revision of the manuscript for important intellectual content. jg-v contributed to obtaining information, reading the manuscript, and critical revision of the manuscript for important intellectual content. ám-e contributed to the research conception and design, obtaining information, data interpretation, reading the manuscript, and critical revision of the manuscript for important intellectual content. all authors contributed to the article and approved the submitted version. times of coronavirus: online education in response to the crisis academic self-esteem, academic self-efficacy and academic achievement: a path analysis american college health association-national college health assessment ii: reference group executive summary spring coronaphobia: fear and the 2019-ncov outbreak anxiety and depression in medical students of a private medical college self-efficacy and academic experiences with university students muestreo mixto on line: una aplicación en poblaciones ocultas the psychological impact of the covid-19 epidemic on college 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autoeficacia académica: un factor determinante para el ajuste académico en la vida universitaria i'm not good for anything and that's why i'm stressed: analysis of the effect of self-efficacy and emotional intelligence on student stress using sem and qca auto-eficacia, sexo y rasgo de ansiedad como moderadores de la ansiedad ante exámenes stress, anxiety, and depression levels in the initial stage of the covid-19 outbreak in a population sample in the northern spain mental health and the covid-19 pandemic self-efficacy, social participation, and perception regarding university services by sex experimental and ex post facto designs public responses to the novel 2019 coronavirus (2019-ncov) in japan: mental health consequences and target populations factors influencing psychological distress during a disease epidemic: data from australia's first outbreak of equine influenza covid stress syndrome: concept, structure, and correlates the outbreak of covid-19 coronavirus and its impact on global mental health the forgotten plague: psychiatric manifestations of ebola, zika, and emerging infectious diseases estudio nacional representativo de las respuestas de los ciudadanos de españa ante la crisis del covid-19: respuestas psicológicas self-efficacy's role in unifying self-regulation theories psychology and covid-19: an analysis from the basic psychological processes immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china study on the public psychological states and its related factors during the outbreak of coronavirus disease 2019 (covid-19) in some regions of china a novel approach of consultation on 2019 novel coronavirus (covid-19)-related psychological and mental problems: structured letter therapy we are grateful to ms. ana yara postigo-fuentes for her assistance with the english language. the supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg. 2020.570017/full#supplementary-material key: cord-254471-4lomiv5d authors: kupcewicz, ewa; grochans, elżbieta; mikla, marzena; kadučáková, helena; jóźwik, marcin title: role of global self-esteem in predicting life satisfaction of nursing students in poland, spain and slovakia date: 2020-07-27 journal: int j environ res public health doi: 10.3390/ijerph17155392 sha: doc_id: 254471 cord_uid: 4lomiv5d background: this study analyzed the role of global self-esteem and selected sociodemographic variables in predicting life satisfaction of nursing students in poland, spain and slovakia. methods: the study subjects were full-time nursing students from three european countries. a diagnostic survey was used as a research method, while the rosenberg self-esteem scale (ses) and the satisfaction with life scale (swls) were used to collect data. results: the research was performed on a group of 1002 students. the mean age of those surveyed was 21.6 (±3.4). the results showed significant differences both in the level of the global self-esteem index (f = 40.74; p < 0.0001) and in the level of general satisfaction with life (f = 12.71; p < 0.0001). a comparison of the structure of results demonstrated that there were significantly fewer students with high self-esteem in spain (11.06%) than in poland (48.27%) and in slovakia (42.05%), while more students with a high sense of life satisfaction were recorded in spain (64.90%) than in poland (37.87%) or in slovakia (47.44%). a positive, statistically significant correlation was found between global self-esteem and satisfaction with life in the group of slovak students (r = 0.37; p < 0.0001), polish students (r = 0.31; p < 0.0001) and spanish students (r = 0.26; p < 0.0001). furthermore, a regression analysis proved that three variables explaining a total of 12% output variation were the predictors of life satisfaction in polish students. the regression factor was positive (ßeta = 0.31; r(2) = 0.12), which indicates a positive correlation and the largest share was attributed to global self-esteem (9%). in the group of spanish students, global self-esteem explained 7% (ßeta = 0.27; r(2) = 0.07) of the output variation and 14% in the group of slovak students (ßeta = 0.38; r(2) = 0.14). conclusions: the global self-esteem demonstrates the predictive power of life satisfaction of nursing students, most clearly marked in the group of slovak students. the measurement of the variables under consideration may facilitate the planning and implementation of programs aimed at increasing self-esteem among young people and promoting the well-being of nursing students. the literature explores various approaches to self-esteem. according to rosenberg, self-esteem is a positive or negative attitude towards oneself, a kind of global self-assessment. at the same time, the author points out that high self-esteem is a belief that one is "good enough", a valuable person, while low self-esteem means dissatisfaction with oneself, a kind of self-rejection [1] . self-esteem is a complex and multifaceted concept, often used interchangeably with self-evaluation [2, 3] . by its very nature, it is a subjective construct, based on personal perception and assessment. it involves not only the emotional, but also the performative aspect of functioning. it is a representative indicator of health and well-being, as well as a variable explaining human behavior [3, 4] . research shows that people with high self-esteem experience more positive emotions and are very active, persistent and healthier. on the other hand, people with low self-esteem experience more negative emotions and show less activity and even an attitude of avoiding difficulties, challenges and risks [3] . there are theoretical assumptions and empirical evidence that global self-esteem is a feature or state. according to mark leary's theory, self-esteem reflects the sociometric position of a person in a group. in turn, self-esteem as a state reflects the level of social approval and acceptance, as well as the sense of group membership and is susceptible to changes under the influence of mood or effort put into the task [5] . studies show that self-esteem changes during human life, increases between late childhood and adolescence and then increases during late adolescence and early adulthood [6] . this is a period related to a young person's education and the formation of new competences with regard to their personal vision of life. it is important that positive feelings, a lack of negative feelings and the level of satisfaction with life should be part of the subjective well-being in the life of every person [7] . the literature offers numerous studies on the evaluation of life satisfaction as a result of comparing one's own situation against the standards set by a given person. the evaluation of life satisfaction is expressed in the sense of satisfaction with one's own achievements and conditions [8, 9] . as the research shows, the level of self-esteem and satisfaction with life among nursing students (as well as among active nurses) varies and it is usually at a moderate level [10] [11] [12] [13] . many researchers have indicated that the variables in question reveal important relationships proving, among other things, the level of individual activity [14] [15] [16] [17] [18] . farwa et al. searched for a link between self-esteem and life satisfaction and socioeconomic status in a group of nursing students at the university of lahore. the results showed a positive correlation between socioeconomic status and self-esteem and student life satisfaction, which, according to the authors of the research, will translate into a more effective study [14] . other studies conducted among a group of 348 chinese students (214 men and 134 women) showed a close relationship between self-esteem and life satisfaction for both women and men. furthermore, the impact of the socioeconomic status on the life satisfaction of the students was observed [15] . an interesting study was conducted at the university of cyprus to determine the relationship between religiousness, self-esteem, stress and depression among students of nursing, social care and early education. self-esteem in that study played a significant role because higher levels of self-esteem in students were associated with lower levels of depression, while the strength of religious and spiritual beliefs negatively correlated with depression [16] . the links between self-esteem and student health were also confirmed by karaca et al. self-esteem, academic satisfaction, stress and negative events over the past year have been shown to have a strong link to mental health in a group of 516 turkish nursing students [17] . other turkish studies at the foundation university in istanbul attempted to determine the impact of four years of nursing studies on the self-esteem and assertiveness of academic youth. it was found that the level of self-esteem in the examined students increased in the fourth year of studies, while the level of assertiveness in the students varied depending on the year of studies, increasing in the second and third year of studies [18] . the relationship between global self-esteem and sociodemographic variables such as age, marital status, level of education and professional experience of nursing students is also evident, as was shown by shresth et al. [19] . the research results also show the relationship between emotional intelligence and self-esteem. the results of a study carried out on a group of 400 nursing students at kafrelsheikh university in egypt can provide an example here. significant positive correlations between variables were observed and it was shown that emotional intelligence and self-esteem are important factors determining student progress. most the examined students demonstrated low and moderate self-esteem [20] . other studies, in turn, show that self-esteem is significantly related to social functioning and plays a significant role in shaping the image of the nursing profession [11] . based on the literature review, it can be concluded that self-esteem shows predicted relationships with emotional dispositions, predispositions determining readiness to take action, as well as aspects of task-oriented and social functioning [6] . in line with the presented theoretical assumptions, the main objectives of this study were established: • the following research hypotheses were put forward: • it is assumed that nursing students have different levels of global self-esteem and life satisfaction depending on their country of origin; • there is a relationship between global self-esteem and selected sociodemographic variables, i.e., age, year of study and gender and satisfaction with life in nursing students from different countries. between may 2018 and june 2019, a diagnostic survey was carried out with the participation of 1002 students enrolled in first degree-undergraduate, full-time studies in the nursing program at the university of warmia and mazury in olsztyn, the pomeranian medical university in szczecin (poland), the university of murcia in murcia (spain) and the catholic university in ružomberok (slovakia). the criteria for inclusion in the study included having the status of a nursing student, age up to 30 and expressed consent to participate in the study. the criteria for exclusion from the study were the period of the examination session and the absence of consent to participate in the study. the research was carried out at the place where the teaching classes for students are held, after obtaining permission from the teacher conducting the classes. one of the researchers delivered the prepared sets of questionnaires to the universities where the research project was carried out. students were provided with information about the purpose of the study and instructions on how to fill in the answer sheet and they had the opportunity to ask questions and receive explanations. after expressing informed consent to participate in the study, students were given a set of questionnaires. on average, it took about 20 min to complete the questionnaire. the research was anonymous and voluntary and the students could withdraw from the study at any time. a total of 1017 sets of questionnaires were distributed. after collecting the data and eliminating defective questionnaires, 1002 (i.e., 98.5%) correctly completed questionnaires were qualified for further analysis. the collected material was entered in excel software and the results were analyzed collectively. the study involved 1002 students, including 404 (40.3%) from poland, 208 (20.8%) from spain and 390 (38.9%) from slovakia. the mean age of all the respondents was 21.60 years (±3.40). the distribution of women and men in different countries was significantly different (p < 0.001). women accounted for 91.32% (n = 915) of all surveyed persons and men only 8.68% (n = 87). the distribution of the number of students in particular years of studies in the analyzed groups was similar. the number of first-year students was 329 (32.83%), the second year: 458 (45.71%) and the number of third-year students was 215 (21.46%). the age of the respondents was analyzed in three age groups: ≤20 years, 21-22 years and ≥23 years. the distribution of age groups by country was significantly different (p < 0.001). among spanish students, 73.08% were 20 and below (table 1 ). the research applied the diagnostic survey method and two research tools (validated and available for general use in the mother tongue in each of the countries) were used to measure variables: a self-constructed questionnaire was used to collect sociodemographic data, such as place of residence (country), gender, age, level of education, form and year of study. rosenberg ses self-esteem scale is made up of 10 statements that relate to beliefs and are diagnostic in their nature. the examined person indicates the extent to which he/she agrees with each of them by providing answers on a four-point scale from 1 to 4, which indicate: 1-strongly agree, 2-agree, 3-disagree, 4-strongly disagree. following the assumed method of evaluating the answers, statements that are positively formulated are reversed: 1, 2, 4, 6, 7, so that the highest score is awarded for answers expressing a higher level of self-assessment. the result is the sum of points, which is an indicator of the overall self-esteem level. the range of possible results is from 10 points to 40 points. a higher score reflected higher self-esteem. raw results were converted into standard units on the sten scale. the ses scale has good psychometric properties, with cronbach's alpha ranging from 0.81 to 0.83 [3,4,6]. the satisfaction with life scale (swls) contains five statements and is used to measure life satisfaction expressed in the sense of satisfaction with one's achievements. the respondent indicates to what extent each of the statements refers to his/her previous life, providing a response on a seven-point scale from 1 to 7, which indicate: 1-strongly disagree, 2-disagree, 3-slightly disagree, 4-neither agree nor disagree, 5-slightly agree, 6-agree, 7-strongly agree. the result is a sum of points, which is an overall indicator of the sense of satisfaction with life. the range of results is from 5 points to 35 points. a higher score indicates greater satisfaction with life. raw results were converted into standard units on the sten scale. the swls scale has good psychometric properties and a reliability factor (cronbach's alpha) is 0.87 [9] . the data generated during the study were subjected to statistical analysis using the polish version of statistica 13 (tibco, palo alto, ca, usa). socio-demographic data are presented as the number of cases and as the percentage values and the distribution of variables in groups for individual countries was checked with the chi-squared (χ 2 ) test. the overall indicator of global self-esteem was converted to standardized units, which were interpreted according to the characteristics of the sten scale. it contains 10 units and the scale jump equals 1 sten. sten scores between 1 and 4 were considered low, between 5 and 6 were considered average and between 7 high and 10 high [6, 9] . differences in average global self-esteem and life satisfaction results among students by country of origin were tested with the anova (f) test, while intergroup differences were tested with the post hoc test. the r-pearson correlation coefficient was used to determine the relationship between the variables. multiple regression analysis was used to build a model of estimation of a random variable from explanatory variables. the interpretation of the strength of the relationship between the variables was based on guilford's classification. in all tests, the significance level p < 0.05 was assumed [21] . the presented research results are part of a larger international research project [22] . the research meets the criteria for a cross-sectional study [23] , and the project received approval (no. 4/2020) from the senate committee on ethics of scientific research at the olsztyn university. the results of research on global self-esteem and life satisfaction conducted in poland, spain and slovakia indicate that global self-assessment is related to the subjective well-being of nursing students. taking into account the cultural conditions in individual countries, significant differences were observed in nursing students both for overall global self-esteem index (f = 40.74; p < 0.0001) and for overall life satisfaction (f = 12.71; p < 0.0001) ( table 2 ). detailed analyses with the post hoc test (nir test) showed that the level of global self-esteem among spanish students was significantly lower than among polish (p < 0.0001) and slovak students (p < 0.0001). however, no significant differences in the level of the overall global self-esteem index were found between students from poland and slovakia (table 2 ; figures 1 and 2) . subsequent analyses with a post hoc test showed that the general level of life satisfaction among nursing students in poland was significantly lower than in slovakia (p < 0.03) and lower than in spain (p < 0.0001). in turn, students from slovakia demonstrated a significantly lower rate of satisfaction with life than students from spain (p < 0.002) ( table 2 , figures 1 and 2) . within a given country, no significant differences in the average results for global self-esteem or sense of satisfaction with life were noted in relation to selected sociodemographic characteristics such as age, gender and year of study. after converting the raw results into sten-scale standardized units, it was found that the distribution of low, average and high global self-esteem in nursing students varied significantly from country to country (χ 2 = 103.66; p < 0.0001). as shown by the analyses, the number of respondents with low self-esteem was significantly higher in spain (37.02%) than in poland (27.97%) and slovakia (26.15%). on the other hand, students with high self-esteem were significantly less numerous in spain (11.06%) than in poland (48.27%) and slovakia (42.05%) ( figure 3) . after converting the raw results into sten-scale standardized units, it was found that the distribution of low, average and high global self-esteem in nursing students varied significantly from country to country (χ 2 = 103.66; p < 0.0001). as shown by the analyses, the number of respondents with low self-esteem was significantly higher in spain (37.02%) than in poland (27.97%) and slovakia (26.15%). on the other hand, students with high self-esteem were significantly less numerous in spain (11.06%) than in poland (48.27%) and slovakia (42.05%) (figure 3 ). after converting the raw results into sten-scale standardized units, it was found that the distribution of low, average and high global self-esteem in nursing students varied significantly from country to country (χ 2 = 103.66; p < 0.0001). as shown by the analyses, the number of respondents with low self-esteem was significantly higher in spain (37.02%) than in poland (27.97%) and slovakia (26.15%). on the other hand, students with high self-esteem were significantly less numerous in spain (11.06%) than in poland (48.27%) and slovakia (42.05%) ( figure 3) . subsequent analyses were associated with the calculation of pearson's linear correlation coefficients (r) between the overall global self-esteem index and life satisfaction of nursing students, determining the strength and direction of the relationship. in the group of slovak students, a statistically significant positive correlation (r = 0.37; p < 0.0001) between global self-esteem and satisfaction with life was observed on an average level ( figure 5 ). the same direction and a similar strength of relationship at the average level were found for polish students. the correlation coefficient was r = 0.31 (p < 0.0001) ( figure 6 ). the lowest correlation coefficient (r = 0.26; p < 0.0001) was observed among spanish students (figure 7) . these results indicate that nursing students with higher global self-esteem are significantly more satisfied with life, regardless of their country of residence. spain slovakia subsequent analyses were associated with the calculation of pearson's linear correlation coefficients (r) between the overall global self-esteem index and life satisfaction of nursing students, determining the strength and direction of the relationship. in the group of slovak students, a statistically significant positive correlation (r = 0.37; p < 0.0001) between global self-esteem and satisfaction with life was observed on an average level ( figure 5 ). the same direction and a similar strength of relationship at the average level were found for polish students. the correlation coefficient was r = 0.31 (p < 0.0001) ( figure 6 ). the lowest correlation coefficient (r = 0.26; p < 0.0001) was observed among spanish students (figure 7) . these results indicate that nursing students with higher global self-esteem are significantly more satisfied with life, regardless of their country of residence. determining the strength and direction of the relationship. in the group of slovak students, a statistically significant positive correlation (r = 0.37; p < 0.0001) between global self-esteem and satisfaction with life was observed on an average level ( figure 5 ). the same direction and a similar strength of relationship at the average level were found for polish students. the correlation coefficient was r = 0.31 (p < 0.0001) ( figure 6 ). the lowest correlation coefficient (r = 0.26; p < 0.0001) was observed among spanish students (figure 7) . these results indicate that nursing students with higher global self-esteem are significantly more satisfied with life, regardless of their country of residence. further analyses attempted to determine the predictors of life satisfaction among the examined nursing students in individual countries. when constructing the multiple regression model, life satisfaction was assumed as the explained (dependent) variable and a range of sociodemographic variables, i.e., age, gender, year of study and global self-esteem, were used as explanatory (independent) variables. regression analysis showed that three variables explaining a total of 12% output variation were the predictors of life satisfaction in polish students ( table 3) further analyses attempted to determine the predictors of life satisfaction among the examined nursing students in individual countries. when constructing the multiple regression model, life satisfaction was assumed as the explained (dependent) variable and a range of sociodemographic variables, i.e., age, gender, year of study and global self-esteem, were used as explanatory (independent) variables. regression analysis showed that three variables explaining a total of 12% output variation were the predictors of life satisfaction in polish students ( table 3 ). the regression further analyses attempted to determine the predictors of life satisfaction among the examined nursing students in individual countries. when constructing the multiple regression model, life satisfaction was assumed as the explained (dependent) variable and a range of sociodemographic variables, i.e., age, gender, year of study and global self-esteem, were used as explanatory (independent) variables. regression analysis showed that three variables explaining a total of 12% output variation were the predictors of life satisfaction in polish students ( table 3 ). the regression factor was positive (ßeta = 0.31; r 2 = 0.12), indicating a positive correlation, with the largest share attributed to global self-esteem (9%). the other two variables, year of study and gender, demonstrated a small share in the prediction of life satisfaction among polish students (3%). in nursing students in spain and slovakia, only one variable-global self-esteem-proved to be a predictor of life satisfaction. in the group of spanish students, global self-esteem explained 7% (ßeta = 0.27; r 2 = 0.07) of the output variation and 14% in the group of slovak students (ßeta = 0.38; r 2 = 0.14). in both cases, the regression index was a positive value, which means that global self-esteem is positively linked to subjective well-being, which is an important element of health. = 0.14; corrected r 2 = 0.14 statistically significant: p < 0.01; p < 0.001. explanation: r-correlation coefficient; r 2 -multiple determination coefficient; ßeta-standardized regression coefficient; ß-non-standardized regression coefficient; ß error-non-standardized regression coefficient error; t-t-test value; ses-global self-esteem. the authors of this study have attempted to define the role of global self-esteem in the lives of nursing students in poland, spain and slovakia, recognizing that self-esteem is based on self-knowledge, which affects satisfaction with life. there are numerous factors that determine how nursing students perceive themselves. the image they create of themselves and the attitude they have towards themselves have a strong influence on a wide range of personal and social behaviors. in this study, significant differences were observed in the level of the overall global self-esteem index among nursing students. students from spain obtained lower average values (26.03) of global self-esteem than nursing students from poland and slovakia (29.69 vs 29.10). comparing the mean values obtained in own research with the mean results (30.85) obtained for the data collected in 53 countries by other researchers, it can be concluded that, as in most countries, most the examined nursing students obtained results higher than the arithmetic midpoint of the scale [22] . the average results of the second examined variable, i.e., life satisfaction, were distributed slightly differently. the highest average value was obtained by students from spain (24.04), while lower values were obtained by students from slovakia (22.40) and poland (21.46 ). when reviewing the results obtained by other researchers, it can be observed that they indicate different levels of global self-esteem and life satisfaction among the groups of respondents, sometimes being quite diverse [10, [24] [25] [26] [27] [28] [29] [30] . velmurugan et al. proved that 65.3% of the surveyed nursing students revealed moderate self-esteem, while 22.9% had low and only 11.9% had high levels of self-esteem [10] . as demonstrated in the analyses of own research results, students with high self-esteem were significantly less numerous in spain (11.06%) than in poland (48.27%) or slovakia (42.05%). in contrast, more than half (64.90%) of the surveyed students from spain described their sense of life satisfaction as high, which may indicate that in addition to self-esteem, other factors have a significant impact on their well-being. in turn, in a study in cyprus, average levels of global self-esteem were found for the majority (71.3%) of nursing students [27] . the results of numerous studies indicate that global self-esteem correlates with life satisfaction [28] [29] [30] . to confirm this thesis, it is worth citing the results of research carried out by patel et al., who found a significant impact of self-esteem on the satisfaction with life of indian students [28] . similarly, in the research presented in this study, the results of linear correlation indicate that the higher global self-esteem among students is correlated with increased satisfaction with life. the presented study also showed that global self-esteem is a predictor of satisfaction with life (from 7% to 14%) of nursing students, and the strongest predictive power was shown in the slovak group. however, sociodemographic variables, i.e., age, gender and year of studies did not play a significant role in predicting the satisfaction of the studied students. several researchers also sought individual determinants of subjective well-being in early adulthood. it was found that students' self-esteem, physical appearance and positive everyday events were indicators of satisfaction with life among spanish youth [29] . in contrast, williams et al. conducted an interesting study to determine the relationship between daily life satisfaction of nursing students and the body mass index (bmi) and the consumption of food and drink. the study group consisted of 215 students, of whom approximately 44.9% were overweight, obese or extremely obese. it was found that the increase in individual satisfaction with everyday life predicted a 36% decrease in the probability of overweight/obesity [30] . self-esteem is a personal resource related to the well-being of working nurses and it makes sense to develop it in the next stages of education. a study by perez-fuentes et al. of a group of 1073 nurses found that global self-esteem correlates strongly with health behavior. the results of these studies have shown that poor sleep quality and the type of food consumed affect the self-esteem of nurses [31] . in other studies, using a group of 1094 nurses, it was found that global self-esteem had a direct and indirect effect on uncontrolled eating [32] . abnormal eating behavior often signals problems with self-esteem, acceptance of one's own body and difficulties with adaptation in the group [33] . research shows that self-esteem has strong links to the dimensions of emotional functioning. consequently, it is important to promote the well-being of students. an illustration of this is a project aimed at promoting the mental health of first-year nursing students at the university of minify (egypt). as a result of the actions taken, there was an increase in self-esteem and a decrease in the level of student anxiety in relation to the initial parameters [34] . korean researchers, on the other hand, evaluated a short program for nursing students that focused on promoting positive self-esteem and ego development, as these two variables are related to academic achievement and students' life satisfaction. as indicated by the authors of the study, the results of self-identity and self-esteem increased significantly in the group of participating students, while the results in the control group remained at the same level [35] . in subsequent korean studies, an attempt was made to identify factors affecting the learning outcomes of nursing students under simulated conditions. it was found that the self-esteem and collective effectiveness of nursing students during team classes in simulated conditions affects their educational effects [36] . there is evidence suggesting that other variables that are expected to be related to the level of self-esteem are key attributes of healthcare workers, such as interpersonal communication, emotional intelligence and empathy [25] . it is worth highlighting that it is impossible to present all directions in which scientific research on self-esteem and satisfaction with life is developing. the authors of the study have only reviewed the most important findings, which may be helpful in interpreting the results of their own research and comparing them with the results of other researchers, as well as outlining the area of future research on the development of global self-esteem and quality of life of academic youth as future employees of the medical services sector. it is also worth considering the new situation recently caused by the covid-19 pandemic, at least in view of the factors related to restrictions which have forced quite a radical change in the functioning of young people, especially in social contacts. in further scientific deliberations, it can be assumed that nursing students with low global self-esteem and low life satisfaction may experience negative emotional states of dissatisfaction in their relationships with others, which may lead, among others, to feelings of loneliness. the results of the research presented in this study show that global self-esteem is a predictor of life satisfaction for nursing students, and its measurement can help to plan and implement programs aimed at increasing the sense of self-esteem of young people and promoting the well-being of students. the authors of the study indicated some limitations, related to the fact that the research did not exclude students experiencing (at that time) family related, financial or emotional problems, not related to studying. since the presented study is the first on the international scene in selected european countries, such as poland, spain and slovakia, it requires replication with a larger study group, as well as verification of the relationships established here in other situational contexts. significant differences in the level of overall global self-esteem and life satisfaction of nursing students based on the country of residence were found. students from spain achieved lower average values of global self-esteem than nursing students from poland and slovakia, but they achieved higher values of satisfaction with life than other students. the percentage shares of low, average and high global self-esteem and life satisfaction among nursing students in particular countries were significantly different. there were fewer students with high self-esteem in spain than in poland or slovakia, while more highly satisfied students were reported in spain than in poland or slovakia. although global self-esteem demonstrates the predictive power of life satisfaction of nursing students in all of the analyzed countries, it is most clearly marked in the group of slovak students. in the polish group, two sociodemographic variables (year of study and gender) slightly influenced the prediction of life satisfaction in nursing students. society and adolescent self-image does high self-esteem cause better performance, interpersonal success, happiness, or healthier lifestyles? skala samooceny ses morrisa rosenberga-polska adaptacja metody the rosenberg self-esteem scale: translation and validation in university students commentary on self-esteem as an interpersonal monitor: the sociometer hypothesis subjective well-being abbreviated three-item versions of the satisfaction with life scale and the harmony in life scale yield as strong psychometric properties as the original scales self-esteem among nursing students the effect self-esteem, major satisfaction and career identity on nurse image, in nursing students perceive the assessment of life satisfaction in a selected group of nurses and midwives members beskid regional chamber of nurses and midwives in bielsko-biala-preliminary reports association of burnout syndrome and global self-esteem among polish nurses the role of age, gender and socio-economic status in self-esteem and life satisfaction of nursing students a cross-lagged model of self-esteem and life satisfaction: gender differences among chinese university students exploring religiosity, self-esteem, stress, and depression among students of a cypriot university relationship between mental health of nursing students and coping, self-esteem and social support the effect of nurse education on the self-esteem and assertiveness of nursing students: a four-year longitudinal study study of self-esteem of nursing students in a nursing college in kathmandu. glob relationship between emotional intelligence and self-esteem among nursing students. egypt analysis of the relationship between stress intensity and coping strategy and the quality of life of nursing students in poland, spain and slovakia strengthening the reporting of observational studies in epidemiology (strobe): explanation and elaboration simultaneous administration of the rosenberg self-esteem scale in 53 nations: exploring the universal and culture-specific features of global self-esteem the relationship between self-esteem, emotional intelligence, and empathy among students from six health professional programs analysis of sociodemographic and psychological variables involved in sleep quality in nurses religious and spiritual beliefs, self-esteem, anxiety, and depression among nursing students self-esteem and life satisfaction among university students of eastern uttar pradesh of india: a demographical perspective prosociality and life satisfaction: a daily-diary investigation among spanish university students nursing student satisfaction with daily life: a holistic approach association with the quality of sleep and the mediating role of eating on self-esteem in healthcare personnel the reasons for doing physical exercise mediate the effect of self-esteem on uncontrolled eating amongst nursing personnel the effect of body dissatisfaction on disordered eating: the mediating role of self-esteem and negative effects in male and female adolescents impact of counseling on self-esteem and anxiety levels among nursing students evaluation of a program on self-esteem and ego-identity for korean nursing students associations of stress, self-esteem, and collective efficacy among nursing students: a descriptive cross-sectional study this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflicts of interest. key: cord-254494-wbfgrez1 authors: shi, chunhong; zhu, haili; liu, jun; zhou, jian; tang, weihong title: barriers to self-management of type 2 diabetes during covid-19 medical isolation: a qualitative study date: 2020-10-14 journal: diabetes metab syndr obes doi: 10.2147/dmso.s268481 sha: doc_id: 254494 cord_uid: wbfgrez1 purpose: diabetes self-management behaviors are necessary to obtain optimum glycemic control, reduce the risk of complications, and improve health outcomes. the covid-19 pandemic imposes an additional struggle for self-management by diabetes patients. although previous studies have reported socio-demographic, behavioral, psychological, and cultural barriers to diabetes self-management, little is known about perceived barriers to diabetes self-management among patients during isolation following their recovery from covid-19. the purpose of this study was to explore perceived barriers among type 2 diabetes patients during isolation following their recovery from covid-19. patients and methods: a qualitative, exploratory, and descriptive research design was utilized. semi-structured telephonic interviews were conducted with 12 patients with diabetes who had been discharged from one covid-19 designated hospital and underwent isolation in the designated facilities in wuhan city, hubei province, china. data were analyzed using colaizzi’s seven steps. results: barriers to diabetes self-management identified by patients with diabetes during isolation were categorized into five major themes: inadequate knowledge and behavioral beliefs, shortage of resources, suffering from health problems, negative emotions, and lack of support. conclusion: perceived barriers to diabetes self-management described by diabetes patients indicated a lack of environmental resources and support strategies to meet their needs. efforts to remove barriers are important in assisting patients with diabetes to improve their quality of life and health outcomes. coronavirus disease 2019 (covid19) , which was declared a public health emergency of international concern by the world health organization (who) on 30 january 2020, has posed a severe threat to global public health. 1,2 diabetes mellitus (dm) is a common chronic disease in china with a prevalence of 10.4%. 3 although people of all ages are generally susceptible to covid-19, patients with diabetes are at higher risk for covid-19 due to the multiple concomitant chronic diseases and immunosuppression. 4, 5 according to the currently published literature, the prevalence of dm among covid-19 patients and critically ill covid-19 patients were 7.4-20.0% [6] [7] [8] [9] and 17%, 10 respectively. the chinese center for disease control and prevention (china cdc) has stipulated that covid-19 patients discharged from hospitals are subject to a 14-day period of isolation and medical observation. 11 as of midnight on august 19, 2020 , the total number of confirmed covid-19 cases had reached 84,895 in china. 12 these facts indicated that a large number of covid-19 patients with diabetes underwent isolation after being discharged from hospitals. patients with diabetes recovering from covid-19, who experienced the chronic hyperglycemic state and persistent inflammatory states, are at higher risk of covid-19 reinfection and the occurrence and progression of dm complications. 13 there is a compelling need for this vulnerable population to reduce this risk through good blood sugar control during their isolation. however, ideal blood sugar levels cannot be maintained solely by anti-diabetic medications; 14 good self-management behaviors play a crucial role in dm treatment-especially for those with type 2 diabetes mellitus (t2dm). 15 self-management refers to long-term, and effective decisions and behaviors, to maintain patients' well-being, which involves medical, behavioral, and emotional management. 16 positive and effective self-management not only alleviates the progression of dm on physiological indicators but also improves the patients' quality of life. 17 scholars from stanford university pioneered the application of the concept and methods of self-management in a community-based diabetes self-management program. 18 these early studies have opened new channels for the prevention, control, and treatment of dm and substantially improved the quality of life of patients with diabetes. 19 promoting effective diabetes self-management has long been a challenging issue for the health systems, healthcare providers, community workers, and patients with diabetes. 20 although the data regarding diabetes management for t2dm patients recovering from covid-19 during isolation remain scarce, notably, previous studies have reported that among chinese t2dm patients, only 22.76%-40.09% have achieved optimal glycemic control (hemoglobin a1c level<7.0%, 53 mmol/mol) 21-23 and 9.20%-16.43% have manifested good self-management behaviors. 21, 24 this raises the issue of how to identify factors that hinder diabetes selfmanagement and to address these potential barriers. studies in developed countries such as the united states, canada, the united kingdom, and singapore have found that common barriers to self-management include poor communication between patients and healthcare providers, limited accessibility to healthcare facilities, lack of family support, inadequate disease knowledge and limited disease treatment methods, lack of motivation for change, physical and cognitive disorders, limited access to diabetes education, and financial barriers. [25] [26] [27] [28] [29] [30] [31] [32] evidently, factors that hinder diabetes self-management are complex and multifaceted. however, the barriers to diabetes self-management for patients with diabetes recovering from covid-19 during their isolation are not precisely known. to date, a considerable amount of literature on glycemic treatment and control in covid-19 patients with preexisting dm has been published. 33, 34 most studies, however, focused on hospital and physician practice, while few studies investigated or mentioned self-management among patients with diabetes during their isolation following recovery from covid-19. a qualitative study is an ideal design for an in-depth understanding of the feelings and experiences of patients with diabetes. such studies are of great significance to elucidate the perceived barriers to diabetes self-management among isolated patients. this study addressed a gap in this field by interviewing patients with diabetes subjected to medical isolation after recovering from covid-19 to gain a deeper understanding of the barriers to diabetes self-management, and provide new perspectives and approaches for the design of interventions and formulation of policies. this study adopted a descriptive qualitative methodology to collect data through telephonic interviews, which provided a rich and thick description of the participants' perceptions of barriers to diabetes self-management. a phenomenological approach was used to achieve an indepth understanding of the factors hindering diabetes selfmanagement from the patient's perspective. 35 participants were recruited through purposive sampling based on the following inclusion criteria: (1) t2dm patients with a disease duration of greater than 1 year, (2) covid-19 patients with diabetes after being discharged from the hospital, (3) had stayed at designated isolation sites for at least 7 days, (4) spoke and understood chinese (mandarin), and (5) agreed to participate in the study. patients with type 1 dm or younger than 18 years old were excluded. the primary researchers of this study, who were nurses at a designated covid-19 hospital in wuhan city, hubei province, china, contacted patients who met the inclusion criteria through the contact information listed on their medical records. the sample size was determined by data saturation-when no new information was obtained during the last two interviews. 36 variations in age, education level, and duration of diabetes were considered to ensure diversity in the perception of barriers to self-management. we followed the consolidated criteria for reporting qualitative research to report the findings of this study. 37 semi-structured, in-depth telephonic interviews were conducted from february 20 to march 4, 2020, at a convenient time after dinner (approximately 19:00-20:00 beijing time) in a quiet and comfortable environment. before each telephonic interview, the primary researchers explained the objectives and methods of the study to the participants, promised to perform confidentiality measures, and obtained verbal informed consent from all participants. all interviews were recorded using a cellphone and a recording pen (newsmy v29, 16 gb internal memory) with the consent of the participants. an interview guide (table 1 ) was used to conduct the interviews, which consisted of a series of open-ended questions regarding the various aspects of self-management. the interview guide was tested using pre-interviews with two patients of diabetes not included in the actual study, which resulted in corrections of the language and content. during the formal interviews, the interviewees were encouraged to express their thoughts and perceptions thoroughly and probing questions, such as, "can you please elaborate on this?" were included to increase the depth of the discussion. the nonverbal information (eg, tone of voice, pause) and the important statements stressed by the patients were documented during the interview. each interview lasted between 15 and 30 minutes. each audio recording was transcribed by a co-author within 24 hours of the interview and reviewed by another author who interviewed the patients to ensure accuracy of the transcript. the interviews, raw transcripts, and data analysis were conducted in mandarin chinese. data analysis was conducted by two co-authors using colaizzi's seven-step method 38 to extract themes and sub-themes. the detailed steps were as follows: (1) reading and re-reading raw data transcribed from the audio recordings; (2) marking and extracting significant statements pertaining to the investigated phenomena; (3) coding recurrent important viewpoints; (4) summarizing all coded viewpoints; (5) elaborating and articulating the meanings of the viewpoints; (6) integrating, categorizing, and refining similar viewpoints into themes; and (7) returning the formulated themes to the interviewees for validation. all authors agreed with the data analysis results. to ensure the rigor of the study, the four criteria of dependability, credibility, transferability, and confirmability were in this study, 12 participants were interviewed. table 2 shows the demographic information of the participants. barriers to diabetes self-management were categorized into five themes: inadequate knowledge and behavioral beliefs, shortage of resources, suffering from health problems, negative emotions, and lack of support, as indicated in table 3 . respondents in the study were found to have poor knowledge, inadequate self-care behavior and low-level beliefs regarding diabetes self-management. the theme "inadequate knowledge and behavioral beliefs" emerged from all discussions that contained three sub-themes, namely, limited diabetes knowledge, confusion about taking medications, and low adherence to self-monitoring of blood glucose. most participants (n=11) alluded to the fact that inadequate diabetes knowledge challenged their management of blood glucose. they often asked for help from those around them (eg, daughter or father). they had limited knowledge regarding diet management and physical exercise. some of them even believed that refraining from sweets and carbohydrate-rich foods or insisting on physical exercise alone could achieve good glycemic control. one female patient stated, "my knowledge regarding diabetes has been gained from my daughter, who is a nurse. she told me which foods i can or cannot eat." (p6) another male participant stated, "my dad also has diabetes. he controls this disease through exercise and obtains good outcomes, so i control my blood glucose by exercising." (p2) a similar view was expressed by another patient, "i know a little about diabetes. i pay little attention to it in daily life and just engage in exercise to control my glucose." (p9) all participants voiced their concerns about medication treatment. more than half of the patients were unfamiliar with the use of hypoglycemic agents. they were confused about taking medications, with most uncertainty involving the names, usage and side effects of the medications, which prevented participants from effectively managing their disease. a female patient expressed unfamiliarity with the usage of hypoglycemic agents: i am worried whether i take too much acarbose. i take two tablets with each meal, and i do not know if it is too much . . . the doctor told me to alternate between metformin and acarbose, which made me confused. (p7) a male patient stated, the hypoglycemic medicines prescribed by the doctor when i was discharged from hospital were different from what i used at home; maybe the effects are the same. i do not know whether these medicines are better or worse than the previous ones, i cannot judge them. (p4) low adherence to self-monitoring of blood glucose among all patients, only one brought test strips and needles to the isolation site. they paid little attention to blood most of the isolation facilities were converted from hotels or high school premises at short notice in response to the demand during the covid-19 pandemic period. the shortage of resources at these facilities was another issue discussed by all patients. this theme consisted of four subthemes: limited space for exercise, unavailability of blood glucose monitoring, absence of a diabetic diet, and undersupply of hypoglycemic medications. at the isolation sites, the participants were largely confined to their rooms because of social distancing policies. all participants described that they exercised daily but could only do so in their rooms or corridors. as a male patient's transcripts showed, regular blood glucose monitoring is essential for glycemic control in diabetes. among all interviewees, only one had performed daily blood glucose monitoring; the remaining participants mentioned that they had not monitored their blood glucose at the isolation sites due to the unavailability of blood glucose monitoring. an elderly female patient stated, all participants were concerned with diet, which is a crucial tool for managing t2dm. 40, 41 in particular, 5 participants clearly expressed that the diet provided at the isolation sites was unsuitable for patients with diabetes. as stated by participant 12, "many food items at the isolation site contain sugar . . . i have no choice but to avoid food items with sugar . . . there is no diabetic diet." (p12) another female patient further added, approximately half of the participants faced issues regarding the shortage of hypoglycemic medications, or medication changes, due to the non-supply of medications at the isolation sites. one participant mentioned, another female patient stated, "the medicines prescribed by the hospital are not enough, i don't know if they can last till the end of the isolation period" (p8). the participants described that they experienced hyperglycemia, physical discomfort, and insomnia during the mandatory isolation after contracting covid-19, which discouraged them from self-managing the diabetes and reduced their motivation to self-manage their diabetes. suffering from health problems is an important obstacle to adherence to self-management behavior. two thirds of the participants stated that their blood glucose levels increased and became difficult to control after contracting covid-19. the unsteady blood glucose made them feel frustrated and impeded their self-efficacy in their journey of diabetes management. as described by one participant, the elevation of blood glucose after contracting covid-19 was also mentioned by another female patient. "after getting covid-19 . . . my blood glucose was above 20 [mmol/l]. it has never been so high over the last 20-odd years." she continued, "blood glucose is difficult to control; i can hardly manage it well." (p12) of note was that half of interviewees still experienced physical discomfort after covid-19 treatment and hospital discharge such as tiredness, shortness of breath, aches and pains, or a headache. these physical symptoms prompted them to focus on covid-19 recovery and treatment while ignoring the self-care of diabetes. another patient also experienced physical discomfort. nearly half of the participants experienced insomnia at the isolation facilities as they were unaccustomed to their isolation environments, subjected to activity constraints, and engaged in fewer social activities. insomnia led to their fatigue, poor concentration, and tension during the day and disrupted their diabetes management routine. the following examples demonstrated this experience. high contagious infectivity, potential fatality of covid-19, loneliness in the isolated room, and difficulties in maintaining blood glucose levels elicited negative emotions in the participants. three quarters of patients with diabetes expressed unpleasant or unhappy emotions toward covid-19 and the isolation environment. such emotions can cloud their judgments and reduce rationality in decision-making on self-management behaviors. negative emotions as a barrier to self-management, emerging from the transcripts, included three sub-themes: stigma, dissatisfaction, and anxiety. participants may have perceived stigma for suffering from covid-19. they feared discrimination from others and avoided full disclosure about their disease to both peers and healthcare workers, thereby influencing the way they view the disease and approach their self-management. a female patient expressed, the isolated patients faced various inconveniences at the isolation sites. some of them complained about the lack of supplies (especially medications) and expressed dissatisfaction with the living conditions and diets provided at the sites. dissatisfaction affected their activation of diabetes self-care and discouraged their behaviors toward diabetes self-management. one participant complained, "the isolation site offers nothing just serves for isolation . . . there's no fruit, no medicine . . . there are too many difficulties for us to manage diabetes." (p8) a male participant expressed his dissatisfaction toward the isolation site, this place isn't as good as the hospital, the room is really tiny . . . the (medical) service here (isolation site) isn't so professional compared with the hospital . . . i just try to control my blood sugar by eating less food. (p9) patients with diabetes often felt stressed and worried about the medication, diabetes supplies, and blood sugar levels. a third of the patients expressed that they were somewhat worried or anxious. this emotional distress often brings about negative consequences for diabetes and further affects their self-management behaviors indirectly. a participant stated, most patients with diabetes who underwent forced isolation perceived a lack of guidance and support. these patients described their experiences as a struggle to trudge along a difficult path of diabetes self-management, as they were unable to seek help from anyone under the constraints of social isolation. lack of support as a theme was expressed by most respondents, which had two subthemes: lack of professional guidance, and lack of family support. most healthcare providers at isolation facilities had been temporarily extracted from various healthcare departments, who might have had little diabetes knowledge and only took responsibility for covid-19 prevention and education. the participants expressed the view that they felt helpless with regard to managing their diabetes without professional guidance. for instance, a participant stated, "every morning, [healthcare providers] only ask if we feel comfortable and measure our body temperature . . . blood glucose is not monitored at the isolation site." (p7) another patient complained that "the doctors here show little concern for us . . . the healthcare providers differ from those at the hospital in terms of professional levels." (p6) the covid-19 isolation policy prohibits face-to-face visits from family members, which greatly affects the patient's access to family support. in addition, covid-19 is characterized by familial aggregation, which also reduced the sources and types of family support provided to the participants. as stated by a divorced female participant, during the isolation period, i have made no phone calls to my family and friends . . . my family members are also staying at the isolation sites, so it is too inconvenient . . . another participant expressed that she could not get actual assistance from her family members as they could only express their concern over the phone, "the concern from my family is of no use . . . sometimes they can't even send things to me because non-staff entering the isolation site is forbidden." (p12) this exploratory and descriptive qualitative study reported the barriers to self-management of t2dm patients who had recovered from covid-19 during medical isolation. five major themes were identified: inadequate knowledge and behavioral beliefs, shortage of resources, suffering from health problems, negative emotions, and lack of support. self-management is essential for prognosis and glycemic control in patients with t2dm. understanding the barriers to self-management will help patients make changes and better manage their diabetes. our results showed that limited knowledge regarding dm is a major barrier to diabetes self-management. participants tended to gain diabetes knowledge from the experiences of people around them. the common assumption was that low educational levels (average below high school) and old age (mean age: 59.75 ±7.93 years) limited their abilities to acquire medical information and seek better healthcare resources. similarly, studies conducted in ethiopia 42 and iraq 43 have indicated that a lack of appropriate information/knowledge hinders self-management among patients with diabetes. a study by ji et al showed that diabetes knowledge is positively correlated with overall self-management behavior. 23 specifically, the higher the level of knowledge on diabetes, the better the self-management behavior of patients with diabetes. 44 additionally, most patients also expressed their confusion about taking medication. low education and lack of diabetes knowledge might provide a possible explanation for this. previous studies have indicated that difficulties and frustrations in taking medications prevented diabetes patients from effectively self-managing. 45 in addition, low adherence to self-monitoring of blood glucose posed another barrier to diabetes self-management, which was consistent with the findings of tewahido et al 42 and mikhael et al. 43 this is more commonly associated with the patients' economic position, fear of needles, the erroneous belief that blood glucose will remain normal with timely medicating, physical activity, and dietary modifications. a study by ji et al 21 also demonstrated that blood glucose monitoring was the lowest priority of patients with diabetes when compared to medications, diet, and physical activity. the results of this study emphasized the importance of improving self-management knowledge and behavioral beliefs in patients with diabetes. efforts directed toward practical and person-centered diabetes selfmanagement education and support programs are necessary to improve patients' knowledge and behavioral beliefs and self-management levels. a shortage of resources was frequently identified as the key factor that inhibited diabetes self-management in this study. issues such as limited space at the isolation sites, unavailability of blood glucose monitoring resources, absence of a diabetic diet, and undersupply of hypoglycemic medications, were repeatedly mentioned by the participants. for instance, some participants expressed that the standardized diet at the isolation sites led to the inability to perform self-management in accordance with their specified nutrition plans. this finding was consistent with previous findings that residing in a community with limited healthy foods and the absence of safe exercise environments may be an important barrier to diabetes self-care and glycemic control. 46, 47 for all participants in this study, the provision of resources needed for diabetes selfmanagement by the isolation facilities was a significant issue. however, as was widely recognized, the locations used for isolation of covid-19 patients had a unified layout and lacked the facilities conducive to diabetes selfmanagement. this finding suggests that creating a favorable environment for self-management of chronic diseases at the isolation sites, such as the provision of a diabetic diet and blood glucose monitoring as part of a daily health management program, is extremely important for the improvement of the quality of life and health of patients. suffering caused by the disease was a great barrier that emerged from the transcripts. this is consistent with the findings of hu et al, 45 in which patients' physical suffering kept them from properly managing their disease. moreover, the results of the present study provided additional evidence that covid-19 may result in elevated blood glucose levels, which was congruent with the findings reported by ilias et al 48 and brufsky. 49 persistently high blood glucose may cause frustration in patients, thereby affecting their passion towards self-management. five participants in this study stated that they suffered from severe insomnia. in keeping with our findings, xue et al 50 also reported significant sleep problems (eg, difficulty falling asleep, early awakenings) in the forced isolation population. in addition, poor sleep quality has been found to be significantly associated with decreased adherence to dietary, lower self-care adherence, and poorer diabetes control. 51 given disease related suffering, it is imperative for healthcare and covid-19 isolation organizations to develop and implement strategies to deliver continuous care for discharged covid-19 patients, especially those with diabetes. negative emotions were discussed as a psychological barrier to self-management. half of the participants felt stigmatized, which was mainly manifested as societal rejection; one-third complained about poor service at the isolation sites, and one-third expressed anxiety. although the public health response to covid-19 has been essential in preventing and containing the epidemic, it may also have aggravated the stigmatization of patients. 52, 53 forced isolation and the associated measures have disrupted the social lives of patients with diabetes, resulting in them feeling fearful and trapped. armitage et al 54 reported that social isolation exposes older adults to greater risks of negative emotions such as depression and anxiety. an online study conducted in italy reported that longer isolation times, combined with smaller physical spaces, led to a deterioration in mental health. 55 moreover, psychological distress affected the medication adherence and self-management of patients with diabetes. 31 kato et al 56 found that the nonadherence behaviors of patients with diabetes may be a response to the internalization of stigma. self-stigma is a negative independent factor that affects the self-care behavior of patients with t2dm. 57 our results confirmed these findings and suggested that greater emphasis should be placed on the mental health of this vulnerable population, and healthcare and covid-19 isolation organizations should adopt multifaceted strategies to eliminate potential drivers of negative emotions in isolated patients. this study revealed that the lack of professional guidance from healthcare providers (eg, self-care measures, maintenance of target blood glucose, monitoring of complications) is a common barrier to diabetes selfmanagement. healthcare providers play a unique role in delivering person-centered diabetes self-management education, supporting interventions, and assisting patients to undertake protective self-care behaviors. 58 other qualitative studies have reported similar findings whereby patients with limited resources were particularly challenged when seeking medical services or obtaining care and support. 59, 60 apart from the scarcity of guidance from healthcare providers, the participants also identified the lack of family support as another barrier to diabetes selfmanagement. during the isolation period, it is difficult for diabetes patients to obtain knowledge, care, and material support from their family members, although this support was essential for promoting lifestyle changes and improving self-management behavior in patients with diabetes. 23 such a result matches the findings of previous studies, which considered family members, friends, and peers of patients with diabetes as primary promoters of selfmanagement. 30, 59, 61 similarly, quantitative studies have also indicated that a higher level of social support is associated with better adherence to recommended selfmanagement behaviors. [62] [63] [64] in conclusion, there was insufficient support to encourage diabetic selfmanagement of the isolated patients. such problems may be resolved by establishing electronic blood glucose records and a remote consultation system to provide practicable diabetes self-management education and support, and by enhancing telephonic and internet-based family support. this study had several limitations. first, we obtained data from a small geographical area (wuhan city) and a small, convenient sample (12 patients with diabetes), which might limit the generalizability of the findings. second, our analysis was based on interview data. therefore, it was impossible to explore the differences between the demographic characteristics (such as gender and education level) of the barriers to diabetes selfmanagement. third, this study explored barriers to diabetes self-management from the patients' perspectives, without considering the experience of healthcare providers and family members. fourth, qualitative studies have inherent limitations, such as the tendency for subjectivity during data analysis. future research should collect data from larger samples or adopt a multicenter approach to obtain a broader view of barriers to diabetes self-management. our findings provide insight into barriers to diabetes selfmanagement among t2dm patients during isolation following recovery from covid-19. we found that inadequate knowledge and behavioral beliefs, shortage of resources, suffering from health problems, negative emotions, and lack of support were barriers to self-management among patients with diabetes. understanding these barriers is beneficial for the formulation of targeted strategies, such as creating favorable isolation environments, strengthening medical and social support, and implementing patient-centered diabetes care, to promote successful self-management. at present, as many countries around the world are still in the critical period of pandemic prevention and control, greater concern should be paid to patients with diabetes during isolation. in addition, open dialogue among patients, healthcare providers, family members, and policy makers can be established to better support patients' diabetes journey and improve health outcomes. this study was approved by the ethics committee of hunan academy of traditional chinese medicine affiliated hospital (approval no.202003-09). we explained the objective, process, and methods of the study to the participants and obtained verbal informed consent prior to each telephonic interview. participants were assigned anonymous identification numbers (p1, p2, etc), and personally identifiable information was deleted from the transcripts to protect patient privacy. the interview data were kept strictly confidential, and all audio recordings and transcripts were stored in a passwordprotected computer. interviewees were free to withdraw from the study at any time without any reason. pneumonia of unknown etiology 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adherence association between social support and self-management behaviors among patients with diabetes in community original research, review, case reports, hypothesis formation, expert opinion and commentaries are all considered for publication. the manuscript management system is completely online and includes a very quick and fair peer-review system we would like to express our gratitude to the hunan academy of traditional chinese medicine affiliated hospital for the approval and support of this study and all participating patients for providing valuable information regarding barriers to the self-management of dm. furthermore, we wish to express our gratitude to the hunan academy of traditional chinese medicine for providing financial and material support. finally, we thank our advisors dr. chunyan li and dr. yinhua zhang for their contribution of valuable insights in the process of this study. the authors report no conflicts of interest in this work. key: cord-285386-kvo544hh authors: wen, ya; chen, huaruo; pang, liman; gu, xueying title: the relationship between emotional intelligence and entrepreneurial self-efficacy of chinese vocational college students date: 2020-06-23 journal: int j environ res public health doi: 10.3390/ijerph17124511 sha: doc_id: 285386 cord_uid: kvo544hh the purpose of this study is to explore the relationship between emotional intelligence and entrepreneurial self-efficacy. the sample consisted of 529 students. the tools used to measure the relationship between emotional intelligence and entrepreneurial self-efficacy were the emotional intelligence scale developed by wong and law and the entrepreneurial self-efficacy scale developed by zhan. the results showed that there was a significant difference between male and female college students in entrepreneurial self-efficacy, but no significant difference between male and female college students in emotional intelligence. in entrepreneurial self-efficacy as well as emotional intelligence, there were significant differences between the third grade and the first and second grade, respectively. in addition, the results showed a significant positive correlation between entrepreneurial self-efficacy and emotional intelligence. with the improvement of the emotional intelligence level of vocational college students, the entrepreneurial self-efficacy will increase. the lower the emotional intelligence, the faster the improvement in entrepreneurial self-efficacy. the higher the emotional intelligence, the more stable the entrepreneurial self-efficacy. the university stage is considered an ideal entrepreneurial period, especially for vocational colleges’ students, who pay more attention to entrepreneurship and innovation education. encouraging the cultivation of the emotional intelligence of vocational college students in life will help to improve personal entrepreneurial self-efficacy. this research emphasizes that improving the emotional intelligence of vocational college students can enhance their sense of self-efficacy in entrepreneurship and help students with entrepreneurship and career development. entrepreneurship is of great significance to a country's economic growth and decline in unemployment [1, 2] . under the policy background of "mass entrepreneurship and innovation" in china, the research on college students' innovation and entrepreneurship has grown exponentially. how to enhance the self-efficacy of college students' entrepreneurship and promote their entrepreneurship and employment to the maximum extent is an important issue for colleges to accelerate economic and social development, improve the talents cultivation pattern, and promote the success of college students [3] . vocational colleges are an important part of china's higher education system, vocational students are the guarantee of technical talents for china's development [4] . generally, they need to study in since 2000, the literature on emotional intelligence has been endless, especially the research on positive psychological qualities such as emotional intelligence and well-being has attracted the attention of many scholars. the relationship between emotional intelligence and subjective well-being was analyzed, supporting emotional intelligence as a key skill for personal growth and social development [22] . there is a positive correlation between trait emotional intelligence and subjective well-being; a negative correlation between emotional intelligence and stress and social anxiety has also been confirmed [23] . regarding the relationship between adolescent emotional intelligence and mental health, many researchers have conducted research and found that adolescents with lower parental violence have higher emotional intelligence, and emotional intelligence is related to positive adolescent development [24] [25] [26] . in addition, studies have found that adolescents with low emotional intelligence report a higher risk of suicide than those with high emotional intelligence [27] . a study of 524 italian college students found that traits of emotional intelligence are a source of happiness and hope [28] . in the field of organizational behavior, emotional intelligence is also concerned by scholars. a study shows that employee emotional intelligence has a positive predictive effect on psychological capital and job performance, and some studies have concluded that the interaction between role ambiguity and emotional intelligence has significant significance in explaining the dimension of engagement [29] [30] [31] . career adaptability is a popular concept in organizational behavior in recent years [32, 33] . a study based on cross-lagged panel analysis found that emotional intelligence can predict career adaptability [34] . in addition, a study of senior managers showed that the relationship between emotional intelligence and occupational personality scales showed that emotional intelligence was positively correlated with many occupational scales [35] . can emotional intelligence be cultivated? how effective is the cultivation? many researchers have discussed this. a meta-analysis of emotional intelligence training shows that, regardless of the form, training interventions for emotional intelligence are considered effective [36, 37] . in the field of organizational behavior, studies have found that interventions on emotional intelligence may effectively improve job satisfaction [38] . an interview-based study found that training nurses' emotional intelligence is beneficial to their mental health [39] . when it comes to entrepreneurial self-efficacy, self-efficacy needs to be discussed. the concept of self-efficacy is derived from bandura's social learning theory. according to the basic perspective of social learning theory, generally speaking, when people are in or facing a predicament that is bad for themselves, many people often show psychological fear and try to avoid or get rid of various unfavorable situations and problems that they think are difficult to cope with [40, 41] . the self-efficacy refers to the ability of individuals to show very decisive judgments and behaviors when they are in or facing such unfavorable situations or problems, to effectively complete tasks, and to overcome difficulties and problems [42, 43] . hackett and betz (1981) proposed to extend the theory of self-efficacy to the career field. at the same time, some researchers applied self-efficacy to the field of entrepreneurship to generate entrepreneurial self-efficacy [44, 45] . some scholars describe entrepreneurial self-efficacy as entrepreneurial self-confidence in specific tasks [46] ; others define entrepreneurial self-efficacy as confidence in individuals' ability to complete the entrepreneurial process [47] . some scholars defined the concept of entrepreneurial self-efficacy from three dimensions: the first dimension is to apply self-efficacy to specific aspects of entrepreneurial spirit; the second dimension is to emphasize the content level of self-efficacy, the third dimension is the validity of self-efficacy belief [48] . entrepreneurial self-efficacy is an important influencing factor of entrepreneurial intention, and entrepreneurial intention is a key indicator of entrepreneurial behavior prediction and interpretation [49] . the relationship between entrepreneurial self-efficacy and entrepreneurial intention has attracted the attention of many scholars, especially in the field of higher education. some researchers have found that there is a positive correlation between the quality of entrepreneurship education and entrepreneurial self-efficacy [50] . in practice-oriented entrepreneurship courses, higher entrepreneurial self-efficacy is associated with higher entrepreneurial intention [51] , and entrepreneurial self-efficacy has a strong predictive effect on entrepreneurial intention [52] . in addition, some researches based on the social career cognition theory (scct) also show that entrepreneurial self-efficacy is positively related to entrepreneurial intention [53] . some scholars have pointed out that entrepreneurial self-efficacy has a strong impact on entrepreneurial self-efficacy for college students [54] . a study of engineering college students found that, in addition to the positive moderation effect of social norms on the relationship between entrepreneurial self-efficacy and entrepreneurial intention, entrepreneurial education is also positively related to the intention of entrepreneurial activities [55] . other researchers have found that the relationship between employment perception, entrepreneurial intention, career adaptability, and self-efficacy of college students and job seekers is positively correlated with career adaptability and general self-efficacy [56] . in summary, entrepreneurial self-efficacy is an important factor affecting entrepreneurial intention, and it is of great significance for individuals to form entrepreneurial intention or to complete entrepreneurial behaviors. entrepreneurial self-efficacy is closely related to the performance of enterprises. a study on the self-efficacy of entrepreneurs in central asia concluded that self-efficacy has a direct and intermediary effect on performance [57] . in addition, the evidence on south african enterprises supports that entrepreneurial self-efficacy is significantly related to the competitiveness of enterprises during the entrepreneurial stage of searching, planning, and integrating resources and personnel [58] . besides, a study on the performance of small french companies has concluded that self-efficacy and work efficiency are positively related to corporate performance [59] . based on multilevel regression analyses, it was found that entrepreneurial self-efficacy can be used as a personal resource to help entrepreneurs turn increasing uncertainty into exploration and opportunity identification [60] . studies by some scholars have shown that entrepreneurial self-efficacy is an important variable in predicting entrepreneurial behavior and entrepreneurial success in the field of entrepreneurship. entrepreneurial self-efficacy is affected by individual internal and external factors, including social, cultural, and economic background, personality, and ability. entrepreneurial motivation, entrepreneurial attention, and participation are extremely significantly correlated with entrepreneurial self-efficacy [61] . in recent years, a large number of studies have shown that entrepreneurial self-efficacy, as an important part of entrepreneurial cognition, is significantly related to entrepreneurial motivation and ability, and has a good predictive effect on entrepreneurial decision-making, behavior, and performance [62] . in addition, the relationship between entrepreneurial self-efficacy and some demographic variables, such as gender, has also attracted the attention of researchers. as early as 2011, some researchers have explored the role models and self-efficacy on the formation of career intentions, and found that role models have a strong effect on females' self-efficacy [63, 64] . some scholars have explored the relationship between the sample's gender role and the entrepreneur's self-efficacy under the cross-cultural background, and the research shows that the entrepreneur's self-efficacy is more affected by the gender role positioning [65] . in addition, a study on entrepreneurial self-efficacy of college students showed that female college students' self-efficacy and the number of entrepreneurial role models were related to increased entrepreneurial intention [66] . at present, there are relatively few studies on the relationship between emotional intelligence and entrepreneurial self-efficacy. some studies have found that entrepreneurial passion has a mediating role in the relationship between self-efficacy and sustainability, indicating that emotion has an important value in entrepreneurship [67] ; based on the fuzzy-set qualitative comparative analysis (fsqca), some researchers conducted causal and effective decision tests on the structural effects of entrepreneurial passion, entrepreneurial self-efficacy, and risk perception [68] . some studies have explored the relationship between emotional intelligence and entrepreneurial self-efficacy. a survey based on britons (16-84 years) showed that the differences in individual entrepreneurship were partly caused by differences in trait emotional intelligence [14] . in addition, some scholars have researched the relationship between entrepreneurial self-efficacy of spanish entrepreneurs and college students and their big five personality and emotional intelligence, and found that entrepreneurs and students with high emotional intelligence have common entrepreneurial psychological characteristics, such as extraversion, openness, high emotional intelligence score, and low neuroticism score [69] . a study showed that there is a significant difference in the entrepreneurial ability of college students with different emotional intelligence levels, and emotional intelligence has a strong predictive power for entrepreneurial ability [70] . emotional intelligence has a good predictive effect on college students' entrepreneurial self-efficacy [71] . vocational colleges are one of the important types of higher education in china, and they are an important part of vocational education. at this stage, college students and undergraduates of vocational colleges belong to the same age group and are comparable and can be used for reference at the same level. from the theoretical perspective, the study of the relationship between entrepreneurial self-efficacy and emotional intelligence of chinese vocational college students is helpful to explore and improve entrepreneurial theory, test the cross-cultural consistency of entrepreneurial theory, and at the same time, expand the research object of emotional intelligence and entrepreneurial self-efficacy. from the perspective of practice, in recent years, china has increasingly emphasized the role of vocational education in the development of social economy. it is of positive value to study the emotional intelligence and entrepreneurial self-efficacy of vocational college students for the development of entrepreneurial education. however, there are few studies on the emotional intelligence and entrepreneurial self-efficacy of students in chinese vocational colleges. in this study, questionnaires were distributed in some provinces of china. among the students of grade 1-3 in liberal arts, science and engineering, and management in more than 10 vocational colleges, a total of 550 students were randomly selected as the objects of investigation. a total of 529 valid questionnaires were collected, with an effective rate of 96%. among them, 290 are male, accounting for 55%; 239 are female, accounting for 45%. there are 196 students in the first grade, 157 in the second grade, and 176 in the third grade. using the entrepreneurial self-efficacy scale (eses) compiled by zhan. the scale has a total of 19 items, which are composed of four factors of opportunity recognition efficacy, relationship efficacy, management efficacy, and risk tolerance efficacy [72] . the basic information of eses is shown in table 1 , and details of topics can be seen in appendix a table a1 . using likert's seven-point scoring method, the higher the score, the higher the level of entrepreneurial self-efficacy in the project. the cronbach's alpha for this study was 0.946. emotional intelligence was measured using wong and law's "emotional intelligence scale" (wleis), the scale has a total of 16 items, including four dimensions of appraisal of self-emotions, appraisal of others' emotions, regulation of emotion, and use of emotion on cognition [73] . the basic information of wleis is shown in table 2 , and details of topics can be seen in appendix a table a2 . using likert's seven-point scoring method, the higher the score, the higher the emotional intelligence in the project. the cronbach's alpha for this study was 0.936. data collection was in the form of paper quality forms distributed in class. first, the education center was contacted, the purpose of the study explained, and authorization requested to complete the scale. the answer of the scale is anonymous, the data filled in by students is confidential, and the research purpose is exclusive. in this study, the distribution, filling, and recovery of the scale were conducted during the class time; the students who participated in filling in the scale were in a suitable environment without external interference for about 30 min. all data were analyzed by spss 25 (ibm, new york, ny, usa) and amos 7.0 (ibm, new york, ny, usa), including descriptive statistics, variance analysis, correlation analysis, and regression analysis. the basic information of the research sample is shown in table 3 . among the vocational college students participating in this study, 37% were first grade, 30% were second grade, and 33% were third grade. of the students, 86% had "work experience" and 14% "no work experience". of the students, 40% had never had entrepreneurship training, 50% of students had attended one or two entrepreneurial courses or lectures, and 10% of students had received more systematic entrepreneurship education. table 4 shows that in terms of entrepreneurial self-efficacy, the overall performance of vocational college students shows a positive trend. the highest score is 133, the lowest is 19, and the median is 99. if the score exceeds the median, the entrepreneurial self-efficacy tends to be positive. in the total scale and scores, the opportunity recognition, relationship, and management mean values of vocational college students' entrepreneurial self-efficacy exceed the corresponding median value, but the overall mean value and risk tolerance are slightly lower than the median value, which shows that the current college students' entrepreneurial self-efficacy tends to be positive, but the overall level is only in the middle level. among them, the average score of opportunity recognition is the highest, followed by relationship, management, and risk tolerance. table 4 shows that in terms of emotional intelligence, the overall trend of vocational college students also shows a positive trend. the highest score of total emotional intelligence scale is 126, the lowest score is 37, and the median score is 85. if the score exceeds the median, it can be considered that the emotional intelligence tends to be positive. in the total scale and scores, the average value of emotional intelligence of vocational college students is higher than the corresponding median value, but only slightly higher than the median value, which shows that the current college students' emotional intelligence tends to be positive, but the overall level is only above the middle level. among them, the average score of use of emotion is the highest, followed by regulation of emotion, appraisal of others' emotions, and appraisal of self-emotions. in order to analyze the correlation between emotional intelligence and entrepreneurial self-efficacy. according to pearson product-moment correlation, there is a correlation between emotional intelligence and entrepreneurial self-efficacy. the correlation coefficient between the two variables is 0.413, which belongs to a moderate degree of correlation. cronbach's alpha reliability values for the scales used are given in table 5 on the diagonals in bold. cfa was used to test whether the measurement model is consistent with the data, and several fitting indexes were calculated to determine whether the structural model is consistent with the sample data. all values obtained from the model fitting index indicate that the model agrees well with the data. table 6 shows the average variance extraction (ave), composite reliability (cr), maximum shared variance (msv), and average square root value. the cr value greater than the specified threshold of 0.7 indicates high reliability. in all of our study structures, the value of ave is greater than 0.5, which indicates a high level of convergent validity. for all variables used in the study, the square root of ave is greater than the inter-structure correlation, which indicates a high level of discriminant validity. when the msv value is less than the ave value, discriminant validity is further established. the results show that all msv values are less than ave, which provides further support for discriminant validity. the scores of entrepreneurial self-efficacy and emotional intelligence of college students of different genders were tested by independent sample t-test (see table 7 ). the results showed that under the condition of homogeneity of variance, there was significant difference between male and female college students in entrepreneurial self-efficacy (t = 3.933, p < 0.001). in the four subscales, opportunity recognition, relationship, and risk tolerance of male college students were significantly higher than that of female college students, and management was not significant. there was no significant difference in emotional intelligence between male and female college students (t = 2.553, p > 0.05). among the four subscales, only appraisal of others' emotions and regulation of emotion are significant. note: * p < 0.05, ** p < 0.01, *** p < 0.001. the scores of entrepreneurial self-efficacy and emotional intelligence of college students in different grades were tested by independent sample t-test (see tables 8 and 9 ). the results showed that under the condition of homogeneity of variance, there was no significant difference in entrepreneurial self-efficacy of college students in grade one, two, and three. in order to explore the specific sources of differences, lsd multiple comparative analysis was carried out. the results showed that there were significant differences between the third grade and the first and second grade, respectively. there was no difference in the opportunity dimension of entrepreneurial self-efficacy among different grades. there was no significant difference in the other dimensions of entrepreneurial self-efficacy between grade one and grade two. there was significant difference in the other dimensions of entrepreneurial self-efficacy between grade one and grade three and grade two and grade three. the results show that, in terms of emotional intelligence, there was no significant difference in entrepreneurial self-efficacy between grade one, grade two, and grade three students. in order to explore the specific sources of differences, lsd multiple comparative analysis was carried out. the results showed that there were significant differences between the emotional intelligence of grade three and grade one and grade two, respectively; there was no significant difference between the emotional intelligence of grade one and grade two college students. a detailed analysis of the regression of entrepreneurial self-efficacy according to different emotional intelligence dimensions shows that there is a linear relationship between entrepreneurial self-efficacy and emotional intelligence of vocational college students, as shown in figure 1 . at the same time, based on the data, according to the research of guerra bustamante et al., this paper divides emotional intelligence into three levels of low, middle, and high according to the standard of percentile, and makes linear regression analysis [74] . on the basis of the regression equation of emotional intelligence and entrepreneurial self-efficacy, especially the state of the slope, we found that when emotional intelligence increases, individuals will think that their entrepreneurial self-efficacy is higher, and when emotional intelligence decreases, individuals have less entrepreneurial self-efficacy. in addition, we also found that when emotional intelligence is low, entrepreneurial self-efficacy improves faster than when emotional intelligence is higher. self-efficacy. in addition, we also found that when emotional intelligence is low, entrepreneurial selfefficacy improves faster than when emotional intelligence is higher. by exploring the emotional intelligence and entrepreneurial self-efficacy of chinese vocational college students, this study expanded the previous literature research concerning emotional intelligence and entrepreneurial self-efficacy of vocational college students. this study explores the entrepreneurial self-efficacy and emotional intelligence of a sample of chinese vocational college students. on the one hand, it broadens the field of emotional intelligence; on the other hand, it explores the factors that affect entrepreneurial self-efficacy. first, our research showed that there is a positive correlation between entrepreneurial self-efficacy and emotional intelligence reported by vocational college students. we also found that entrepreneurial self-efficacy increased most quickly when emotional intelligence was low, and entrepreneurial self-efficacy was more stable when emotional intelligence was higher. we found that the total score of male entrepreneurial self-efficacy of vocational college students was significantly higher than that of female students, which shows that from the overall point of view, male students are more confident in entrepreneurship than female students. similar results have been obtained in other studies. zhou and yang, taking undergraduates and postgraduates as samples, found that male scores in entrepreneurial self-efficacy were significantly higher than female scores [75] . jin's research on college students also found that male students scored significantly higher than female students in all dimensions of entrepreneurial self-efficacy [76] . specifically, opportunities recognition, relationship, and risk tolerance of male college students were significantly higher than that of female college students, and management was not significant, which may be related to the impact of traditional chinese culture on women. for vocational college students, the difference in the management was not significant, which is also a noteworthy discovery. this study found that there was no significant difference in emotional intelligence between male and female students in vocational colleges. previous studies have shown that the difference between men and women in emotional intelligence has been inconclusive. specifically, there were significant differences between male and female college students in appraisal of others' emotions and regulation by exploring the emotional intelligence and entrepreneurial self-efficacy of chinese vocational college students, this study expanded the previous literature research concerning emotional intelligence and entrepreneurial self-efficacy of vocational college students. this study explores the entrepreneurial self-efficacy and emotional intelligence of a sample of chinese vocational college students. on the one hand, it broadens the field of emotional intelligence; on the other hand, it explores the factors that affect entrepreneurial self-efficacy. first, our research showed that there is a positive correlation between entrepreneurial self-efficacy and emotional intelligence reported by vocational college students. we also found that entrepreneurial self-efficacy increased most quickly when emotional intelligence was low, and entrepreneurial self-efficacy was more stable when emotional intelligence was higher. we found that the total score of male entrepreneurial self-efficacy of vocational college students was significantly higher than that of female students, which shows that from the overall point of view, male students are more confident in entrepreneurship than female students. similar results have been obtained in other studies. zhou and yang, taking undergraduates and postgraduates as samples, found that male scores in entrepreneurial self-efficacy were significantly higher than female scores [75] . jin's research on college students also found that male students scored significantly higher than female students in all dimensions of entrepreneurial self-efficacy [76] . specifically, opportunities recognition, relationship, and risk tolerance of male college students were significantly higher than that of female college students, and management was not significant, which may be related to the impact of traditional chinese culture on women. for vocational college students, the difference in the management was not significant, which is also a noteworthy discovery. this study found that there was no significant difference in emotional intelligence between male and female students in vocational colleges. previous studies have shown that the difference between men and women in emotional intelligence has been inconclusive. specifically, there were significant differences between male and female college students in appraisal of others' emotions and regulation of emotion. satsangi and agarwal et al. found that there was significant gender difference in emotional intelligence of postgraduates, and female postgraduates reported higher emotional intelligence scores [77] . zhao et al. showed that there was no significant gender difference in emotional intelligence of chinese college students [78] . marzuki et al. did not find gender differences in emotional intelligence among university students [79] . on the one hand, the gender difference of emotional intelligence of vocational college students may be related to the scale selected for measurement; on the other hand, although the same scale may have an impact on the measurement results, such as the number of subjects sampled, region, nationality, and so on, it may be possible to find the reasons from the fields of biology, psychology, sociology, education, and so forth. in this study, the comparison of entrepreneurial self-efficacy among the three grades found that the entrepreneurial self-efficacy of the third grade students was significantly higher than that of the first and second grade students, and there was no significant difference between the first and second grade students. this is different from some studies. for example, chen and yin's research showed that there is no significant difference in entrepreneurial self-efficacy among college students of different grades [80] .the result of this study may be that the college students in vocational colleges need to find jobs in the third grade, and it may be more difficult for the college students in vocational colleges to find jobs than the general four-year undergraduate students in china. in this context, entrepreneurship, as an important employment path, may be actively concerned by the graduates in the third grade. therefore, the third grade students have a higher sense of entrepreneurship self-efficacy. on the comparison of emotional intelligence of three grades of students in vocational colleges, it was found that the emotional intelligence of the third grade students was significantly higher than that of the first and second grade students, and there was no significant difference between the first and second grade students, which is different from the previous research. lu et al. investigated the emotional intelligence of vocational college students and found that the emotional intelligence of junior students was lower than that of freshmen and sophomores; zhang and xu also found that there was a period of low emotional intelligence in the junior students [81, 82] . the emotional intelligence of the junior school students in this study was higher than that of the students in other grades, probably because with the growth of individual age comes the enrichment of life experience, the increase of college students' maturity, the improvement of their perception of self and other emotions, and the more effective management and regulation of their own emotions [83, 84] . as in previous studies, we found that there was a significant positive correlation between entrepreneurial self-efficacy and emotional intelligence, indicating that emotional intelligence is one of the influencing factors of entrepreneurial self-efficacy. people with high emotional intelligence also have strong entrepreneurial self-efficacy, which may be due to the importance of self-perception and self-regulation in the development of entrepreneurial self-efficacy, while emotional intelligence involves emotional evaluation and regulation, which may promote the improvement of entrepreneurial self-efficacy [85] . in addition, the results showed that emotional intelligence had a significant negative correlation with gender, a significant positive correlation with grade, and a significant negative correlation with major. there was a significant negative correlation between entrepreneurial self-efficacy and gender, a significant positive correlation between entrepreneurial self-efficacy and grade, and a significant negative correlation between entrepreneurial self-efficacy and major. in conclusion, the correlation between entrepreneurial self-efficacy and emotional intelligence was high, and gender, age and other variables had little relationship with entrepreneurial self-efficacy and emotional intelligence. the correlation coefficient between entrepreneurial self-efficacy and emotional intelligence was large, indicating that college students with high emotional intelligence also have a stronger entrepreneurial self-efficacy. the entrepreneurial process means the establishment and maintenance of multiple interpersonal relationships, which means more competition and pressure. managing and regulating one's emotions is an essential quality for successful entrepreneurs [12, 86, 87] . only when entrepreneurs have the ability to control and adjust their own emotions, and know how to think in a different way, can they form a higher sense of self-efficacy, and have the confidence to recognize entrepreneurial opportunities in the environment, conduct interpersonal relationship management, entrepreneurial management, and tolerate entrepreneurial risks [88] [89] [90] . at the same time, we found that when emotional intelligence is at a lower level, the improvement of entrepreneurial self-efficacy is more obvious; while when emotional intelligence is at a higher level, the improvement of entrepreneurial self-efficacy is relatively slow. this seems to indicate that when the emotional intelligence of vocational college students is low, improving the individual's emotional intelligence is more likely to improve students' entrepreneurial self-efficacy. however, when the level of emotional intelligence of college students is high, the improvement of entrepreneurial self-efficacy becomes relatively slow. does this mean that at this stage, in addition to emotional intelligence having a certain predictive effect on entrepreneurial self-efficacy, other factors may also have some impact on entrepreneurial self-efficacy, such as some personality characteristics, psychological qualities of the individual, or some other external factors [91] [92] [93] . there are some limitations when explaining current research. first, the cross-sectional design was used in this study, and the relationship between the variables cannot be explained causally. from this perspective, longitudinal research is more likely to clarify the relationship between entrepreneurial self-efficacy and emotional intelligence of vocational college students [94] . moreover, the sample size selected in this study was limited. perhaps a larger sample size will make the effect of this study more obvious [95] . the findings of this study require more college students from vocational colleges to participate in repeated tests before they are more likely to increase the universality of our results. although this study has some limitations, this study also has its unique value. previous studies have studied the factors that affect entrepreneurial self-efficacy, but there is less research on the relationship between emotional intelligence and entrepreneurial self-efficacy. besides, an interesting finding of this study is that individuals with different emotional intelligence levels have significant differences in entrepreneurial self-efficacy, which is also a complement to previous research. this research is not only of special significance to the entrepreneurship education of chinese vocational college students, but also may play a positive role in the entrepreneurship education of other technical students with similar background of higher education in the world. in the 21st century of the knowledge economy, the successful entrepreneurship of an individual is inseparable from a high sense of entrepreneurial self-efficacy. it is particularly important to carry out entrepreneurship education at the university stage to improve the individual's entrepreneurial self-efficacy [96] [97] [98] . for example, in the design of undergraduate entrepreneurship education, emotional intelligence is included, and social and emotional learning courses are referenced to comprehensively improve the emotional intelligence of college students in vocational colleges in china, helping to improve college students' entrepreneurial self-efficacy [99] [100] [101] [102] . in addition, future research also needs to consider other factors, such as entrepreneurial personality and entrepreneurial passion, which affect vocational college students' entrepreneurial self-efficacy, in addition to emotional intelligence. finally, on the basis of on a comprehensive exploration of the factors that affect entrepreneurial self-efficacy, emotional intelligence and other factors are incorporated into the system of entrepreneurship education for vocational college students. through the combination of multiple factors, the improvement of entrepreneurial self-efficacy can be promoted among college students, thus increasing the probability of successful entrepreneurial behavior, creating the entrepreneurial environment for chinese vocational college students and other similar higher-education-system students in the world, improving the employment quality of college students, and promoting the social and economic development. in summary, it is important to study the relationship between entrepreneurial self-efficacy and emotional intelligence of college students in chinese vocational colleges. in order to further enhance the entrepreneurial self-efficacy of college students in vocational colleges, the future research can try the following three aspects: first, improve the educational training path for college students' emotional intelligence; second, explore related factors that affect entrepreneurial self-efficacy in addition to emotional intelligence and explore the common mechanism of emotional intelligence and other factors on the entrepreneurial self-efficacy of vocational college students; third, explore the influence of emotional intelligence, entrepreneurial self-efficacy, and other variables on entrepreneurial intention of students in chinese vocational colleges. author contributions: y.w. was pi for the project. h.c., x.g. and y.w. developed the questionnaires. l.p. collected the data. h.c. developed the analytical plan and did the statistical analyses. y.w., h.c. and x.g. interpreted the outcomes of the statistical analysis and wrote the paper. all authors have read and agreed to the published version of the manuscript. entrepreneurship as a solution to extreme poverty: a review and future research directions comparative international entrepreneurship: a review and research agenda entrepreneurship in china a cross-temporal meta-analysis of changes in chinese vocational college students' mental health: 1999~2016 the empirical research on 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license acknowledgments: these authors would like to thank yao jijun (working in nanjing normal university) for his great support in data analysis and writing revision. the authors declare no conflict of interest. key: cord-349712-7xte6v2q authors: linde, annika; plymoth, amelie title: letter to the editor date: 2016-08-08 journal: clin epidemiol doi: 10.2147/clep.s111574 sha: doc_id: 349712 cord_uid: 7xte6v2q nan it was with great interest that we noticed that other researchers are also interested in participant-collected nasal swabs to detect pathogens in acute respiratory infections, and we welcome the findings presented in the study by vargas et al. 1 of importance is that already in the beginning of 2015, we showed in our research work that nasal self-sampling is feasible in large-scale surveillance of respiratory infections. 2 we developed a scheme for self-sampling with nasal swabs as part of the study of work environment and disease epidemiology-infections (swede-i). this populationbased, prospective study of work-related risk factors for transmission of viral infections was based on a study cohort of a random selection from the gainfully employed population of a medium-sized town in central sweden. the cohort consisted of 2,237 men and women aged 25-63 years old, who reported all instances of respiratory tract infection or gastroenteritis from september 2011 to may 2012, and sent their self-sampled nasal swabs for analysis, by regular mail. a total of 1,843 samples were received and analyzed for 14 viruses. of the samples received, 876 (47.5%; 95% confidence interval: 45.3% to 49.8%) were shown to contain at least one virus. the average weekly delay between disease onset and the arrival of the specimens at the laboratory varied between 4 and 6 days. the corresponding median delay was between 3.5 and 6 days. picorna-and coronaviruses dominated in specimens obtained from the self-sampling scheme, which is in line with results from previous community-based studies. the self-sampling results were contrasted to those of the contemporaneous routine clinical sampling from the same age group, in the adjacent stockholm county. although higher proportions of positive samples for respiratory syncytial and influenza viruses were observed in the clinical sampling scheme, estimations of seasonality for influenza a and picornaviruses derived from both schemes were similar. our findings show that nasal self-sampling is feasible in large-scale surveillance of respiratory infections, and opens up new prospects for population-based, virologically verified research on virus spread, burden of disease, and effects of environmental factors or interventions. the authors report no conflicts of interest in this communication. pilot study of participant-collected nasal swabs for acute respiratory infections in a low-income, urban population self-sampling for analysis of respiratory viruses in a large-scale epidemiological study in sweden submit your manuscript here: https://www.dovepress.com/clinical-epidemiology-journal clinical epidemiology is an international, peer-reviewed, open access, online journal focusing on disease and drug epidemiology, identification of risk factors and screening procedures to develop optimal preventative initiatives and programs. specific topics include: diagnosis, prognosis, treatment, screening, prevention, risk factor modification, systematic reviews, risk and safety of medical interventions, epidemiology and biostatistical methods, and evaluation of guidelines, translational medicine, health policies and economic evaluations. the manuscript management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. key: cord-030800-fgvc3qw8 authors: tao, yun; bi, xiao-yan; deng, min title: the impact of parent–child attachment on self-injury behavior: negative emotion and emotional coping style as serial mediators date: 2020-07-31 journal: front psychol doi: 10.3389/fpsyg.2020.01477 sha: doc_id: 30800 cord_uid: fgvc3qw8 in order to explore the relationship between parent–child attachment, negative emotion, emotional coping style, and self-injury behavior, 662 junior high school students in four junior middle schools in china’s yunnan province were investigated using a parent–child attachment questionnaire, adolescent negative emotion questionnaire, emotional coping style scale, and adolescent self-injury behavior scale. as a result, two mediate models were created to explain how parent–child attachment affects self-injury behavior. negative emotion and emotional coping style play serial mediating roles in mother–child and father–child attachment models, respectively. the results show that negative emotion mediates between self-injury behavior and both father–child and mother–child attachment, while emotional coping style only functions between father–child attachment and self-injury behavior. by means of bootstrap analysis, negative emotion and emotional coping style have serial mediating roles concerning the impact of parent–child attachment on self-injury behavior. by comparison, the father–child and mother–child attachment have different mediating models: the former relies on emotional coping style, while the latter is associated with emotional experiences. this implies that parent–child attachment has different mechanisms in triggering self-injury behavior, which is in line with the hypothesis of attachment specificity. non-suicidal self-injury (hereafter referred to as nssi or self-injury) is the direct, deliberate destruction of one's own body tissue in the absence of suicidal intent, which is intended by the individual, rather than accidental (klonsky and olino, 2008; nock and favazza, 2009) . the incidence of self-injury among the general population is 1 ≤ 4% (sleuwaegen et al., 2017) ; however, adolescents with a history of self-injury are up by 30-40% (yulong et al., 2016; cerutti et al., 2018) . domestic studies show that the proportion of self-injury behavior among teenagers is over 20% (feng, 2008; ying et al., 2013; yinqgian et al., 2015) . thus, there is clearly a high occurrence of self-injury behavior, especially among adolescents. self-injury behavior is a negative way for individuals to deal with current problems (sornberger et al., 2013) , and causes great harm to adolescents' mental health (guvendeger et al., 2017; baetens et al., 2019) . at the same time, selfinjury behavior is also a risk factor leading to suicide. in the absence of intervention, it may lead to a high possibility of suicide among people (guan et al., 2012; ge et al., 2014) . the biosocial model also holds that an ineffective family environment is an important cause of self-injury behavior, and parents' neglect of children's emotion and abuse can most directly cause self-injury behavior (thomassin et al., 2016) . the parent-child relationship is unavoidably related to the formation and sustainable development of self-injury behavior in junior high school students. in the face of increasingly severe self-injury behavior, previous research has mainly investigated the effects of adverse family environments on adolescents' self-injury behavior, such as early traumatic experiences, emotional susceptibility, personality characteristics, stressful life events, family conflicts, etc. (fuxia et al., 2018; buser et al., 2019) . a strong parent-child attachment with an emotional link in their relationship may to some extent prevent junior high school students from self-injury behavior. however, the mechanism of how parent-child attachment affects adolescents' self-injury behavior still remains unclear. therefore, this paper mainly discusses the impact of parent-child attachment on one's self-injury behavior as well as the mechanism behind it, in an attempt to offer targeted suggestions for the prevention and intervention of self-injury behavior in junior high school students. parent-child attachment is a relatively stable relationship model formed in the communication between children and their parents, which can significantly influence children's social communication and mental health during their growth (yulong, 2015) . a study demonstrates that there are various and unique associations between family based risk factors and self-injury behavior, as well as addictive features (martin et al., 2016) . it is worth noting that the experience of adverse family life is correlated with self-injury behavior. in addition, another study shows that high-quality family relationships, such as parent-child trust and parent-child communication, were linked to fewer discipline violations, less antisocial behavior (burk and laursen, 2010) , and lower levels of anxiety, depression (nadorff et al., 2014) , and loneliness, which may further contribute to middle school students' higher emotional levels (al-yagon, 2012), their seeking help, and more positive ways to adapt to society, thus reducing the probability of selfinjury. on the contrary, the higher the degree of parentchild alienation, the higher the risk of self-injury (weihua, 2016) . in the period of adolescence, junior high school students are going through drastic changes both psychologically and physiologically, being faced with a series of adaptation problems, including physiological maturity, cognitive development, and social role transformation (guoliang and yu, 2018) . thus, when they fail to cope with family relationships, they may alleviate their pain by means of self-injury behavior (victor et al., 2012) . fuxia et al., 2018 has pointed out that parent-child attachment is an important factor in adolescents' self-injury behavior (fuxia et al., 2018) . in addition, recent studies have demonstrated that poor-quality parent-child attachment can increase the incidence of self-injury behavior (honglei et al., 2018) . interpersonal or systematic models have also pointed out that self-injury is the result of family dysfunction, and that the family environment of certain individuals will unconsciously support or strengthen their self-injury behavior (crouch and wright, 2004) . moreover, studies find that fathers and mothers play different roles in parent-child communication; the father spends relatively less time interacting with their children, and tends to engage in more physical and outdoor activities, while mothers invest time and are involved in more caring and household interactions (oliveri et al., 2018) . consequently, it is possible that father-child and motherchild relationships represent different variables that affect the self-injury behavior of junior high school students. previous research says that children have fewer problematic behaviors with a healthy father-child relationship (hardcastle et al., 2018) . meanwhile, the attachment specific hypothesis further indicates that when children undergo attachment experience with different caregivers, the multiple layers of attachment formed boast a non-differentiated degree of influence on children's social and psychological development (zborowski and mcnamara, 1998) ; i.e., the influence of father-child and mother-child attachment on children's development is not superimposed or comprehensive, but independent from one another. do father-child and mother-child attachments have the same impact on self-injury behavior? we will explore their respective mechanisms. at present, the mechanism of how parent-child attachment influences self-injury behavior stills remains unclear and requires further exploration. two main theories used to explain selfinjury behavior are the interpersonal or systematic models, as well as the emotion regulation model (yulong et al., 2016) . interpersonal or systematic models emphasize the impact of the family environment on self-injury behavior, demonstrating the influence of the family system on adolescent problematic behavior, especially from the perspective of parent-child relationships (crouch and wright, 2004) . by contrast, the emotion regulation model shows that individual self-injury behavior is a behavioral strategy to deal with negative emotions or reduce pain from the angle of emotional management (messer and fremouw, 2008) . however, these two models do not explore the negative emotions caused by parentchild relationship in the family system, so they fail to fully reveal the effects of parent-child attachment on negative emotions, emotional coping style, and self-injury behavior. in other words, the question is, as negative emotions are generated by poor parent-child relationship, why are children unable to manage their emotions effectively, and why is parent-child attachment not protective to self-injury behavior? a possible explanation is that, due to negative emotions, individuals choose self-injury behavior as a coping method, which is influenced by the parent-child relationship. a poor attachment relationship may strengthen the connection between negative emotions and self-injury behavior; good attachment weakens it. adolescents, lacking in emotional regulation and control, can possibly resort to self-punishment when facing environment changes and negative emotions. this kind of emotional coping style gives junior high school students the tendency to adopt self-injury behavior instead of other approaches when faced with poor family relationships (glassman et al., 2007) . therefore, in order to examine how and when father-child and mother-child attachment were linked to adolescents' self-injury behavior, negative emotion and emotional coping style are listed as possible mediating factors. negative emotion is a general term for subjective stress and unpleasant experiences (watson et al., 1988) , which reflects individual differences in emotional stability (watson, 2000) . previous studies have found that high-quality parent-child attachments can reduce the influence of negative emotions on individuals, and vice versa (yinqgian et al., 2015) . yan et al. (2018) have also discovered that good parent-child relationships can meet individual's emotional needs, while low-quality relationships may contribute to negative emotions as the result of parent-child alienation (yan et al., 2018) . furthermore, some studies have suggested that mother-child attachment can be directly employed to predict negative emotions, while some other studies have showed that the father-child attachment has no such obvious effect, which means the impact of the former outweighs that of the latter (yinqgian et al., 2015) . thus, all these studies have demonstrated that unhealthy father-child and mother-child attachment can directly trigger junior high school students' negative emotions, and that the influencing mechanisms are actually different. on the other hand, negative emotions may bring about self-injury behavior. a study has found that individuals with high negative emotions can probably relieve their emotional burdens through self-injury behavior, and may weaken the psycho-social function of junior high school students, leading to a series of problems inducing depression and anxiety (yulong et al., 2019) . the experiential avoidance model and emotional management model on selfinjury behavior also proposes that individuals will eliminate their unhealthy emotions through self-injury behavior when lacking an effective emotional management ability or to avoid unpleasant emotions (paivio and mcculloch, 2004; chapman et al., 2006) ; i.e., individuals manage their negative emotions by means of self-injury behavior (quanquan et al., 2017) . further, more studies have also confirmed that there is a significant positive correlation between negative emotion and self-injury behavior (yulong et al., 2019) . generally speaking, negative emotion, as a mediate variable, has a wide range of impacts on individual's cognition, motivation, and social behavior. therefore, based on the model above, it is assumed that negative emotion is to some extent related to the self-injury behavior of junior high school students. thus, we expected negative emotion may play a mediating role between father-child and mother-child attachment and selfinjury behavior. coping style refers to the strategies adopted by individuals to relieve stress under pressure (runxin and jianmei, 2016) , i.e., problem and emotional coping styles (folkman and lazarus, 1980) . some researchers have pointed out that people are more likely to adopt emotional coping methods such as enduring, escaping, venting, fantasy, and denial, when people believe there is no way out (folkman and lazarus, 1980) . probing into literature, guerreiro et al. have found that self-injury behavior is linked to emotional-directed coping strategies (guerreiro et al., 2013) . people with self-injury behaviors tend to take emotional responses, and individuals constantly resorting to emotional responses are more likely to injure themselves when dealing with adverse emotions (cramer et al., 2017) .with an observation of 965 adolescents, castro and kirchner (2017) have made it clear that adolescents with multiple self-injury behaviors would employ more coping strategies like venting, which has therefore proven a risk factor for self-injury. the evidence above shows that emotional coping style is closely associated with self-injury behavior. in a family, an adverse parent-child relationship is the direct cause of emotional coping styles (qiangqin, 2010) . as junior high school students lack social experience, when they suffer an adverse parent-child relationship, they most probably have a sense of inability, not knowing how to change their situation and being apt to resort to emotional coping methods. attachment theory has also proposed that the secure attachment formed earlier between children and their caregivers can affect the coping styles of junior middle school students (davila and levy, 2006) . meanwhile, qiangqin, 2010 has also found that father-child attachment and motherchild attachment could both significantly negatively predict emotional coping style (qiangqin, 2010) . considering this, we expected emotional coping style may play a mediating role between father-child and mother-child attachment and selfinjury behavior. moreover, there is also a close positive correlation between negative emotion and emotional coping style. domestic researchers have discovered that emotional problems are positively related to their coping styles; foreign studies suggest that negative emotion can lead to individuals reacting with such coping styles as avoiding, denying, and enduring, where emotional coping style is considered as a "response to emotion" (folkman and lazarus, 1980) . to sum up, it is believed that negative emotion may affect emotional coping style; therefore, it is essential to examine the serial mediating roles of these two factors in the correlations between father or mother-child attachment and self-injury behavior. the present study's main objective is to analyze the different roles of father-child and mother-child attachment in the development of self-injury behavior of adolescents. thus, we aim to observe the associations between parentchild attachment, negative emotion, emotional coping style, and self-injury behavior. lastly, we will analyze the pathways through which father-child and mother-child attachment is linked to self-injury behavior. therefore, this research has been guided by four objectives. first, we expected parentchild attachment to be associated with self-injury behavior, and there to be a difference between the effects of fatherchild attachment and mother-child attachment on self-injury behavior. second, we anticipated that negative emotion may play a mediating role between father-child and mother-child attachment and self-injury behavior. third, we expected emotional coping style may play a mediating role between fatherchild and mother-child attachment and self-injury behavior. finally, we expected there to be a serial mediating role played by negative emotion and emotional coping style in the correlations between father or mother-child attachment and self-injury behavior. participants for this study were recruited from the junior high schools in china's yunnan province. six hundred and seventy students were approached to take part in this study. the final sample consisted of 309 (46.7%) boys and 353 (53.3%) girls. in reference to the participants' schooling, 198 were in the first year of junior high school, 204 in the second year, and 260 in the third. the age range was between 13 and 18 (m = 15.04, sd = 1.92). the data were collected by means of cluster random sampling in the four junior high schools. ethical approval for this project was given by the executive council of yunnan normal university. the adolescents signed their informed consent. data collection occurred in a classroom context, in the presence of the supervising researcher who, in a succinct manner, administered the standard instructions, including the general objectives of the study as well as guaranteeing free will, privacy, anonymity, and confidentiality of all the information provided. parent-child attachment questionnaire (inventory of parent and peer attachment, ippa) the parent-child attachment questionnaire, compiled by armsden and greenberg (1987) , was translated by wendao et al. (2008) for use in china. this questionnaire in its revised form is composed of 75 questions that are distributed in three subquestionnaires, from which we adopt two sub-questionnaires in this study: the father-child attachment questionnaire-"i think my father is a competent father"; the mother-child attachment questionnaire-"my mother respects my feelings". each fatherchild and mother-child attachment questionnaire included 25 items, which were divided into three dimensions: trust, communication, and alienation. for each item, there are five answer options given for the father and the mother separately, in which the responses are presented on a likert style scale that varies between 1 (totally disagree) and 5 (totally agree). in this study, the cronbach's alpha coefficients of each dimension on the father scale were 0.89, 0.87, and 0.74, respectively, and those on the mother scale were 0.88, 0.87, and 0.72 separately. the negative emotion questionnaire translated into chinese by wenfeng and jianxin (2004) from the original version by bradburne and tyrrell (1969) was used with the objective of evaluating the negative emotional experience from the last 6 months. we used the sub-questionnaire of the negative affect scale. it includes six items-"i feel like i'm upset for some reason." for each item, there are four answer options, presented on a likert style scale, which varies between 1 (never) and 4 (always). the higher the score, the more intense the negative emotion. the psychometric studies performed in the present sample revealed a cronbach's alpha coefficient of 0.79. the coping style scale by shulin et al. (2000) was used to evaluate adolescents' emotional response to problems or troubles. this questionnaire in its revised form consists of 36 questions that are distributed in two sub-questionnaires. we used the subquestionnaire of the emotional coping style scale (17 items), which presents itself in four dimensions: endurance (4 item)-"i buried the unpleasant things in my heart, " escape (4 item)-"refuse to believe that bad things have happened, " venting emotion (4item)-"you will be very upset and vent to your family and friends when you can't solve the problem, " and fantasy denial (5item)-"love to do something unrealistic to eliminate trouble." for each item, there are four answer options, presented on a likert style scale, which vary between 1 (not adopt) and 4 (always adopt). the psychometric studies performed in the present sample revealed a cronbach's alpha coefficient of 0.81. the adolescent self-injury behavior scale, translated into chinese by fang et al. (2015) from the original version of the ottawa self-injury scale, was used with the objective of evaluating the adolescents' self-injury behavior from the past year. it includes 10 items-"deliberately burying your head in the water." the frequency of self-injury behavior in each way was set to 0 times, 1 time, 2-4 times, or 5 times or more, and the total score of the items was calculated as a continuous variable. the psychometric studies performed in the present sample revealed a cronbach's alpha coefficient of 0.95. the present study is of a cross-sectional nature given that the set of measurements were all carried out at the same moment in time. data treatment was carried out using the statistical program spss-statistical package for social sciences, version 22.0 for windows, and the mediate model was tested with amos 21.0. in order to test the mediating effect, the percentile bootstrap method for deviation correction was used, which is recommended by jie and minqiang (2012) . in order to control the common method deviation, we told all participants that the questionnaires were filled out anonymously, and all the data were strictly confidential and only used for scientific research. the harman single factor method was adopted to test common method deviation, and thus the exploratory factor analysis for all variables referred to in the research was carried out. the results show that the eigenvalues of 12 factors are greater than 1, and the variation explained by the first factor is 15.76%, less than 40%, which means that there is no common method deviation in this study (hao and lirong, 2004) . a total of 662 participants were recruited for the study, with the response rate being 98.8%. among the respondents, 64.3% of males and 65.1% of females never committed self-injury behavior; 58.5 and 70.9% of those who never self-injured were from rural and urban areas respectively; 79.4, 71.4, and 78.6% of the never-selfinjured students were in their first, second, and third year, respectively ( table 1) . the results of the inter-scale correlations and the respective averages and standard deviations, reported in table 2 , allow us to state that there are correlations between the variables being studied. the correlation analysis showed that there was positive correlation between mother-child and father-child attachment, but negative correlation with negative emotion, emotional coping style, and self-injury behavior. meanwhile, negative emotion, emotional coping style, and self-injury behavior were positively correlated with each other. the mediating effects of the quality of negative emotion and the emotional coping style variable were calculated using the structural equations model, through the realization of the steps of the percentile bootstrap method. the analysis of the mediating roles of the negative emotion and emotional coping style were carried out, taking into account all of the following dimensions: the negative emotion, the emotional coping style (endurance, escape, venting emotion, fantasy, and denial) as serial mediators of both the parent-child attachment (trust, communication, and alienation), and self-injury behavior. in regard to the model test that verified the parent-child attachment and self-injury behavior, the model test verified that initially. the results are listed as below. the father-child attachment model fits well (χ 2 /df = 4.21, rmsea = 0.06, nfi = 0.98, ifi = 0.97, cfi = 0.99, srmr = 0.04), and the attachment can significantly negatively affect self-injury behavior (β = −0.40, p < 0.001). the mother-child attachment model is also well fitted (χ 2 /df = 4.09, rmsea = 0.07, nfi = 0.99, ifi = 0.98, cfi = 0.97, srmr = 0.04), and this attachment can significantly negatively affect self-injury behavior (β = −0.30, p < 0.001). in summary, the father-child attachment and mother-child attachment can both significantly negatively affect self-injury behavior. the fitting degrees of the structural model and the data of fatherchild attachment were tested, and the results show that the fitting indexes of the model are sound: χ 2 /df = 2.07, rmsea = 0.04, nfi = 0.95, ifi = 0.97, cfi = 0.96, srmr = 0.03, as displayed in figure 1 . the normalized load of all the observed variables on corresponding latent variables is between 0.51 and 0.73, and the composite reliability values are all larger than the standard value of 0.6, indicating that the measurement model has reached the ideal standard, and the observed variables can well reflect the corresponding latent variables. thus, the structural model can be further tested. with negative emotion and emotion coping style taken into consideration, the significant paths are as follows: father-child attachment has a direct negative effect on negative emotion (β = −0.37, p < 0.001) and selfinjury behavior (β = −0.20, p < 0.001); negative emotion positively affects emotional coping style (β = 0.45, p < 0.001) and self-injury behavior (β = 0.21, p < 0.001); and emotional coping style positively affects self-injury behavior (β = 0.28, p < 0.01). furthermore, the percentile bootstrap method of deviation correction was employed to test mediating effects (jie and minqiang, 2012) . 5000 bootstrap samples were extracted from the original data (n ≤ 662) by repeated random sampling, and the bootstrap 95% confidence interval of the mediating effect was calculated. the results, as are demonstrated in table 3 , show that the bootstrap 95% confidence interval of the mediating paths above do not include 0, which means that father-child attachment can affect self-injury behavior through the mediating role of negative emotion and emotional coping style, and that negative emotion and emotional coping style play a serial mediating role between father-child attachment and self-injury behavior. the fitting degrees of the structural model and data of motherchild attachment were tested, and the results indicate that the fitting indexes are sound: χ 2 /df = 3.08, rmsea = 0.06, nfi = 0.91, ifi = 0.94, cfi = 0.95, srmr = 0.04, as represented in figure 2 . the observed variables can well reflect the corresponding latent variables (the calculation method is the same as above); therefore, the structural model can be further tested. with negative emotion and emotion coping style *p < 0.05, **p < 0.01, ***p < 0.001, the same as below. figure 1 | father-child attachment mediate model. father-child attachment→negative emotion→self-injury behavior −0.19*** −0.13 −0.06 father-child attachment→emotional coping style→self-injury behavior −0.08** −0.11 −0.10 father-child attachment→negative emotion→emotional coping style→self-injury behavior −0.09*** −0.08 −0.04 the lower limit and upper limit of boot ci respectively refer to the lower and upper limits of the 95% confidence interval of the indirect effect estimated with percentile bootstrap method to correct deviation; all values retain two decimal places, the same as below. *p < 0.05, **p < 0.01, ***p < 0.001. taken into account, the significant paths are as follows: motherchild attachment can directly negatively affect negative emotion (β = −0.38, p < 0.001) and self-injury behavior (β = −0.15, p < 0.001); negative emotion can positively affect emotional coping style (β = 0.51, p < 0.001) and self-injury behavior (β = 0.12, p < 0.001); and emotional coping style can positively affect self-injury behavior (β = 0.22, p < 0.01). in addition, the percentile bootstrap method of deviation correction is adopted to test mediating effects. the results, as are listed in table 4 , demonstrate that the 95% confidence interval of the mediating paths above do not include 0, indicating that the mediating effect is significant. in other words, motherchild attachment could affect self-injury behavior through the mediating effect of negative emotion, with negative emotion and mother-child attachment→negative emotion→self-injury behavior −0.10*** −0.13 −0.06 mother-child attachment→negative emotion→emotional coping style→self-injury behavior −0.09*** −0.21 −0.05 *p < 0.05, **p < 0.01, ***p < 0.001. emotional coping style playing serial mediating role between mother-child attachment and self-injury behavior. the direct effect of parent-child attachment on self-injury behavior this study finds that father-child and mother-child attachment of junior high school students can both directly negatively influence self-injury behavior, which conforms to the basic view of interpersonal or systematic models (crouch and wright, 2004) . this also supports the conclusion of previous studies; i.e., adverse parent-child attachment will lead to the students' selfinjury behavior (martin et al., 2016; gromatsky et al., 2017) . family relationships are critical to adolescents, and they tend to adopt self-injury instead of other means to ease the tension and stress once the relationships fall ill. some studies have discovered that a high-quality parent-child relationship is a protective factor. when there is a poor quality parent-child relationship, children are more likely to resort to self-injury (glenn and klonsky, 2010) , which means that a healthy parent-child relationship is an essential factor to prevent junior high school students from self-injury behavior. in addition, the higher the score of parentchild attachment, the lower the score of individual self-injury behavior, i.e., the better the quality of attachment, the more trust and cooperation between parents and children, and the lower the possibility of individual self-injury behavior. this research finds that negative emotion can mediate between father-child and mother-child attachment and self-injury behavior, i.e., parent-child attachment can not only directly, but also indirectly, effect self-injury behavior through negative emotion. it also testifies the main principles of theexperience avoidance model and emotion management model (paivio and mcculloch, 2004; chapman et al., 2006) . it demonstrates that parent-child relationships can induce negative emotion, which will further trigger the occurrence of self-injury, both being consistent with the previous studies (klonsky et al., 2003; feng, 2008) . when the individuals lack the ability to manage their negative emotion effectively, they try to relieve the emotion through self-injury. thus, it is certain that negative emotion increases the risk of self-injury behavior. additionally, father-child attachment can be negatively associated with emotional coping style, and the latter further effects self-injury behavior, which is in line with the results of previous studies (qiangqin, 2010; castro and kirchner, 2017) . owing to the lack of experience to cope with social problems, junior high school students do not know how to deal with challenging problems and tend to adopt emotional coping styles after suffering from father-child conflict. however, the emotional coping style puts more emphasis on emotion itself, which is not conducive to solving the problems, but reinforces the negative emotion and even leads to self-injury. studies have shown that the students being accustomed to the emotional coping style are slow at communication, with a significantly higher level of anxiety and depression compared with the general population, and previous studies have also proven that the continuous negative emotional coping style can result in self-injury (konick and gutierrez, 2005) . it shows that a poor quality father-child relationship will increase the chance of emotional coping style by junior high school students, thus increasing their self-injury behavior. in terms of mother-child attachment, however, a poor relationship cannot directly affect emotional coping style, which is inconsistent with former studies (qiangqin, 2010) . this is because mothers, as the main supporter of the children's lives, have established a close relationship with their children from an early age. such a bond tends to be more emotionally connected. therefore, the unhealthy mother-child attachment does not easily lead to an emotional response. at the same time, negative emotion and emotional coping style play serial mediating roles between father-child and mother-child attachment and self-injury behavior. it is believed that junior high school students can have negative emotions due to poor quality parent-child attachment (yulong et al., 2016) , under the influence of which individuals resort to a series of solutions to adapt to their negative emotions. with a sense of inability in emotional processing, they naturally surrender to the emotional coping style, which further contributes to self-injury behavior (folkman and lazarus, 1980; castro and kirchner, 2017) . as children grow up, fathers will use games and set challenges to encourage children to face dangers, overcome difficulties, and promote children's social adaptability (paquette, 2004) , which may serve as an effective indicator of adolescents' psychological elasticity (xiaoyan et al., 2011) ; mothers, however, tend to be more emotionally connected with their children. recent research has also suggested that father-child attachment and mother-child attachment have different roles in the parent-child relationship. father-child attachment has a more significant role in promoting children to cope with challenges and emotions, while mother-child attachment is mainly reflected in emotional experience. therefore, the intermediate model in this study is in line with the attachment specific hypothesis. the mother-child attachment model tends to affect emotional experience, while the father-child attachment model would affect behavioral coping style. this shows that a child's emotional connection with his mother is the basis and starting point for exploring the outside world and will affect his whole life. this is because in the early attachment relationship, infants and children internalize the interaction experience with their attachment objects into their internal working mode. when they contact others later, the internal working model will guide his behavior performance, which also supports the attachment theory. fathers are often a role model who encourages their children to face and solve problems, which is line with previous explanations (gottman, 1998) . the reason for this difference may come from traditional family rearing pattern of "strict father and gentle mother," and adolescents generally hold the stereotype that mothers are more sensitive, gentle, and modest, while fathers are decisive, independent, and vigorous, so the latter is usually imitated by children (chuanhua et al., 2003) . this study proves that father-child attachment is highly predictive of individuals' stress response, which means that father-child attachment, via words and deeds, may change the way junior high school students cope with their emotions. maybe fathers with bad behaviors such as alcoholism, smoking, etc., are more likely to pass their emotional coping styles to their children; however, mother-child attachment does not have this effect, i.e., mothers emotional coping style has less of an effect on children. in other words, mother-child attachment more depends on emotional communication and expression, so an unhealthy mother-child relationship brings more negative emotional feelings. in a word, the quality of mother-child attachment and fatherchild attachment embodies the trust and cooperation between parents and children, but they have different connotations (yan, 2016) . for example, parent-child attachment mainly promotes the emotional communication between parents and children through caring and nurturing behaviors, while parent-child attachment mainly reflects the quality of parent-child attachment by setting an example and giving confidence. the connotation of this attachment is also reflected in the process of emotional adaptation and emotional management. mothers show more emotional warmth and understanding, but fathers demonstrate more problem-solving, so mother-child attachment establishes relationship quality through positive emotions, while fatherchild attachment reflects relationship quality through problemsolving and positive response. parent-child attachment plays an important positive role in the healthy development of individuals; however, unhealthy attachment can destroy the ability for emotional adaptation and regulation. it not only directly affects the self-injury behavior of individuals, but also influences the self-injury behavior through negative emotions and negative emotional coping styles. this study provides a new angle for the intervention and education of self-injury behavior, i.e., from the perspective of attachment theory, paying attention to the impacts of fatherchild attachment and mother-child attachment work models on individual self-injury behavior. attachment mode not only has gender differences, but also differences between safe attachment and non-safe attachment. future research should further explore the relationship between non-safe attachment individuals and the relationship among negative emotion, emotional coping style, and self-injury behavior. in addition, there are some shortcomings in the study as well. first, as a cross-sectional study, the relationship between different attachment types and junior high school students' self-injury behavior could not be examined in more detail. future research may use tracking design to deepen this issue. second, this study has only examined the impact of parent-child and mother-child attachment on self-injury behavior, without referring to peer attachment. in fact, junior high school students' attachment targets are not limited to parents; peer attachment is also of huge importance. studies have suggested that the role of peer attachment has even surpassed that of parent-child attachment in their development (bogaerts et al., 2006) , but there are other different perspectives, so future research may further explore the impact of peer attachment on junior high school students' self-injury behavior. third, the measurement of each variable is entirely based on the self-report of junior high school students; the method of measuring self-injury behavior specifically is relatively single, and there may be social approval effects. thus, future research may consider combining multiple methods to obtain more comprehensive data. fourth, the measured groups are all students, and the sample size is relatively small. in later research, more group samples could be considered for investigation. first, mother-child and father-child attachment directly negatively influences self-injury behavior of junior high school students. second, father-child attachment affects self-injury behavior through separate mediation of negative emotion, through separate mediating effects of emotional coping style, and r through serial mediating effects of negative emotion and emotional coping style. third, mother-child attachment affects self-injury behavior through separate mediation of negative emotion, and through serial mediating effects of negative emotion and emotional coping style. the datasets generated for this study are available on request to the corresponding author. 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 to participate in this study was provided by the participants' legal guardian/next of kin. written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article. yt conceived the study, participated in its design, carried out the study, performed the statistical analysis, and drafted the manuscript. md and x-yb supervised the study, participated in the design of the study, helped to draft the manuscript, and revised the manuscript critically. all authors read and approved the final manuscript. this study was supported by the natural science foundation's "cognitive control of ethnic bilinguals" fund of yunnan normal university (31660282) and project from yunnan province ministry of education fund (2020j0680). adolescents with learning disabilities: socioemotional and behavioral functioning and attachment relationships with fathers, mothers, and teachers the inventory of parent and peer attachment: individual differences and their relationship to psychological wellbeing in adolescence non-suicidal self-injury in adolescence: longitudinal associations with psychological distress and rumination recalled parental bonding and personality disorders in a sample of exhibitionists: a comparative study the propagation of "coronaviruses" in tissue-culture mother and adolescent reports of associations between child behavior problems and mother-child relationship qualities: 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delclós-lópez, gabriel; expósito, francisca; fernández-artamendi, sergio title: the effect of prescription drugs and alcohol consumption on intimate partner violence victim blaming date: 2020-07-01 journal: int j environ res public health doi: 10.3390/ijerph17134747 sha: doc_id: 264629 cord_uid: kuknvemy intimate partner violence (ipv) is a public health problem with harsh consequences for women’s well-being. social attitudes towards victims of ipv have a big impact on the perpetuation of this phenomenon. moreover, specific problems such as the abuse of alcohol and drugs by ipv victims could have an effect on blame attributions towards them. the aim of this study was to evaluate whether the external perception (study 1) and self-perception (study 2) of blame were influenced by the victims’ use and abuse of alcohol or by the victims’ use of psychotropic prescription drugs. results of the first study (n = 136 participants) showed a significantly higher blame attribution towards female victims with alcohol abuse compared to those without it. no significant differences were found on blame attributed to those with psychotropic prescription drugs abuse and the control group. results of the second study (n = 195 female victims of interpersonal violence) showed that alcohol consumption is associated with higher self-blame and self-blame cognitions among ipv victims. however, results did not show significant differences on self-blame associated to the victims’ use of psychotropic prescription drugs. our findings indicate that alcohol consumption, but not prescription drugs use, plays a relevant role in the attribution of blame by general population and self-blame by victims of ipv. intimate partner violence (ipv) is defined as the violence committed by a current or former partner [1, 2] and it includes any behavior "that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviors" [3] . worldwide, almost one third of women who have been in a romantic relationship report having experienced some form of physical and/or sexual victimization by their partner in their lifetime [4] . in fact, the 2030 agenda of sustainable development goals (sdgs) encourages all countries to eradicate ipv, since violence can negatively affect women's physical, psychological and sexual wellbeing, increasing the risk of a poorer health, and it is associated with childhood trauma [5, 6] . the most severe consequence of ipv is death, and 38% of the female murders are currently attributed to this form of violence [4] . moreover, ipv can also have a negative impact on women's economic and social outcomes [7] , as well as on mental health (e.g., depression; [8] ), which might eventually turn into alcohol and drugs abuse [9] . ipv victims blame themselves for the violence they have experienced [10] . moreover, they are judged as more blameworthy by the society when they have violated gender roles [11] . such feelings of blame have an important role on the perpetuation of this phenomenon, and they are related to adversely negative mental health consequences, including substance abuse [12] . however, the relation between ipv and substance use and abuse remains understudied. data indicates that, among welfare recipients, victims of recent physical partner violence show higher rates of alcohol dependence (8%), compared to those who experienced physical partner violence in the past (2.6%) and those who have not experienced physical partner violence (1.1%) [13] . women exposed to ipv have also shown to be more likely to use psychotropic drugs, even after controlling for mental health [14] . according to research, substance use might become a coping strategy for facing continuous violent experiences [15, 16] since victims expect that substances will alleviate the negative physical and psychological impact of ipv [17] . moreover, psychological violence has shown to undermine adaptative coping strategies such as social support among victims of ipv, leading to drug abuse problems [18] . gezinki, gonzalez-pons and rogers [9] concluded that survivors use alcohol and self-medication as a coping mechanism while abuse is occurring, in order to reduce pain; and after the relationship, victims use alcohol and self-medication as a way of coping with the trauma and the stress of building a new life. however, kaysen and collaborators [19] have shown that the use of alcohol as a coping strategy may act as a mediator in the relation between alcohol use and trauma symptoms among ipv victims. in accordance with this approach, alcohol and drugs have been commonly understood as a consequence of the violence [17, 20] . one additional factor aggravating the negative consequences of ipv is social attitudes. as flood and pease [21] asserted: "attitudes play a role in the perpetration of this violence, in victims' responses to victimization, and in community responses to violence against women (p. 125)". these authors assert that women's response to intimate personal violence is determined by their attitudes towards ipv as well as by the attitudes of those around them. social attitudes towards intimate partner violence influence women's perception of support and help in an ipv situation [22] . stereotypic beliefs about intimate partner violence influence people's evaluation of the victim, and "cultural beliefs around ipv de-legitimize individuals who have experienced partner abuse, often blaming those who have experienced ipv for their own victimization" [23] (p. 3). more specifically, one critical attitude towards ipv victims in the general population is victim-blaming, which is defined as the process in which the victim is overtly or covertly attributed fault for their actions or inactions as the reason for the negative outcome [24] . victim-blaming provokes that women not fitting into the traditional gender roles are negatively judged for the violence they are suffering [25] . since the stereotypical features of an ipv victim are passivity and weakness [26] , any deviation of such stereotypical view increases victim-blaming. accordingly, empirical evidence has shown that women are judged more harshly in situations of sexual violence if they are behaving against traditional gender norms [21, 27, 28] . viki and abrams [29] demonstrated that female victims of sexual violence who have violated traditional gender roles are highly blamed by individuals who endorse sexism. therefore, gender norms are limiting women's acceptable behaviors and individual choices [11] . victim-blaming is also important given its effect on external support provided in ipv situations. victim-blaming has shown to be the mediator in the relationship between social attitudes and intervention in ipv situations [30] . when ipv victims are blamed for the violence experimented, they will encounter more obstacles when asking for help. firstly, because they might self-blame themselves. secondly, because they will anticipate that such social victim-blaming will turn into lower help. moreover, female victims not fitting in the traditional gender roles are negatively judged in terms of blame [31] : "women who fail to conform to traditional expectations, either based on their occupations or their actions, are perceived as less warm and this lack of warmth leads to more blame and negativity in a psychological abuse context" [31] (p. 849). self-blame is defined as the attribution of the cause of a traumatic event to one's own actions, assuming the responsibility of the event [32] and hindering recovery [32, 33] . self-blame is a criterion for post-traumatic stress disorder (ptsd) in the diagnostic statistic manual fifth version (dsm-5) [34] and plays an important role on intimate partner victimization (physical, psychological and sexual abuse). according to andrews and brewin [35] , attribution of blame in individuals that have suffered traumatic violent experiences is a learned process where they may be more likely to blame their character, which is linked to lower levels of self-esteem. reich and collaborators [32] have confirmed that self-blame has negative psychological consequences on ipv victims. in addition, according to the transtheoretical model of behavior change [36] internal blame attribution has been associated with the pre-contemplation phase in ipv victims. moreover, women focused on feelings of guilt and self-blame have higher substance abuse and stay in the abusive relationship for a longer period of time [12] . as a consequence, internal attribution of blame enhances the mental health negative effects of ipv among victims, including higher levels of depression and lower levels of self-esteem, damaged psychological adjustment [12, 32, 37] and lower perceived social support. being male or female entails different expectations about social behaviors [38] . gender has shown to be a crucial variable determining drug use as socially acceptable or unacceptable [39, 40] . in this line, brabete, sánchez-lópez, cuéllar-floresa and rivas-diez [41] showed a negative relation between alcohol consumption and traditional female gender norms. although a traditional feminine gender role might work as a protective factor for adverse health habits, it might also be detrimental for social perception and victim blame. in fact, previous studies have shown that women who use drugs report high levels of self-blame, shame, depressive mood, anxiety and tend to use substances more frequently alone and in private rather than in public settings [42] . moreover, according to capezza and arriaga [31] , non-traditional women are blamed more when they are attributed a lack of warmth. following the stereotype content model [43] , drug users would be considered low in competence and low on warmth, labeled as completely cold [44] . this means that women using substances would face an increased stigma since they go against expected female roles. in this direction, since a man drinking alcohol is more socially acceptable than a woman drinking alcohol [45] , drinking among ipv victims will increase victim blame. romero-sánchez et al. [46] showed that the victim's alcohol consumption influences victim blaming to a higher extent than the use of physical strength by the perpetrator. moreover, victims who use substances are perceived as less truthful, leading to higher victim blaming [47] . another study by stewart and maddren [48] showed that drunk victims of family violence were blamed more than non-drunk victims. however, despite previous studies suggesting the effect of drinking on ipv victim-blaming, no previous research has explored the differential effect of alcohol intake and other psychotropic drugs use on victim-blaming among ipv victims. the current study aims to explore the effect of prescription drugs and alcohol use on intimate partner violence victim blaming. our study has two different goals: (1) to assess the perception of the general population of women victims of ipv that use either alcohol or prescription drugs and (2) to determine whether there is a relationship between the use of alcohol/prescription drugs and self-blaming among ipv victims. with this design, we took a two-sided approach to examine how alcohol and prescription drugs influence intimate partner violence victim blaming. given that substantial research has shown the importance of social perception in the use of both legal and illegal drugs [49] , the first study used an experimental design to explore the detrimental effect of alcohol abuse and prescription drugs abuse on the social perception of the ipv victim. considering gender roles on drinking and drugs is of great importance [50] , in the second study, we took a needed gender perspective because "the gender lens asks us to study substance use more carefully and to recognize the impact of social and cultural constructions of masculinity and femininity on individual and group drug use" [51] (p. 286). this gender perspective is necessary since alcohol use is significantly higher among men [50] whereas psychotropic drugs use is higher among women [52] [53] [54] . therefore, a correlational study was carried out among victims of intimate partner violence to evaluate whether alcohol and psychotropic drug consumption are positively related to self-blaming. in order to understand the role of alcohol and psychotropic prescription drugs on ipv victim blaming from a social and victim perspective, two studies were carried out, with two different samples and two different recruitment strategies. the first experimental study was carried out with a paper-and-pencil technique, which allows for a better control of confounding variables and environmental distractors by the experimenter. the second study used an online sampling method for recruiting women meeting the established inclusion criteria. in this case, the online sampling method facilitated a higher perception of anonymity, which was crucial for the study given the sensitivity of the topic [55] . the hypotheses of the first study are: victim-blaming would be higher when an alcohol abuse problem existed in comparison to a control condition without an alcohol abuse problem. victim-blaming would be higher when the victim was an abuser of prescription drugs compared to a control condition without prescription drug abuse. the hypotheses of the second study are: hypothesis 3 (h3). victims of ipv that have an alcohol abuse problem would report higher levels of self-blaming (hypothesis 3a) and higher self-blame cognitions (hypothesis 3b) than those women without an alcohol abuse problem. alcohol consumption is positively related to self-blaming (hypothesis 4a) and self-blaming cognitions (hypothesis 4b) among ipv victims. victims of intimate partner violence who have ever used prescription drugs would self-blame themselves more (hypothesis 5a) and would have higher self-blaming cognitions (hypothesis 5b) compared to women who do not report any prescription drugs use. there is a positive correlation between prescription drugs use duration and self-blaming (hypothesis 6a) and self-blaming cognitions (hypothesis 6b) among ipv victims. a total of one hundred and fifty-five participants participated in the study. nineteen of them were excluded from the analysis due to invalid data, leaving a total of 136 participants. the majority of participants self-identified as heterosexual (94.9%), and 52.2% were women. on average, participants were 30.40 years old (sd = 13.61). modal education was a university degree (58.1%). the research study entitled "psychosocial factors related to the perception of intimate partner violence" was approved by the ethical committee of loyola university previous data collection. following an incidental sampling procedure in different crowded places (e.g., libraries) of a spanish city, a researcher requested the participants' collaboration answering a paper-and-pencil study. all participants were volunteers and provided informed written consent, and no monetary incentives were provided for participation. a between-subjects manipulation was used, where two identical ipv scenarios were created, except for the manipulation of the alcohol or prescription drug abuse problem reported by the victim of the interpersonal violence. after a random assignment of the manipulation, victim-blaming was assessed embedded within a larger series of questionnaires. interpersonal violence scenarios: three scenarios were created to incorporate the experimental manipulation from nguyen et al. [56] second scenario. this scenario described a fictitious dating violence situation between carlos and ana, who were involved in a romantic relationship. the scenarios varied exclusively in the information regarding ana's substance abuse (psychotropic prescription drug abuse condition, alcohol abuse condition and control condition). the scenario provided to participants was as follows: "carlos and ana have been dating for about four years, both are students at the university (alcohol condition: and ana has alcohol abuse problems) (psychotropic prescription drug condition: and ana has psychotropic prescription drug abuse problems). one day, ana went out with her friends and then came over to see carlos. carlos had been working hard on a project for one of his classes. he had wanted ana to help him with this task and was very angry at ana her for going out with her friends. he was quite upset and slapped her fairly hard. she fell and broke a bone in her hand. this required a visit to the emergency room to reset the hand and to get pain pills" (adapted from nguyen et al.; scenario 2 [56] ). victim blame: six questions from romero-sánchez, megías and krahé [57] were used to assess victim blame: "do you believe ana should feel guilty for what happened at the end of this story?" "do you believe ana incited carlos to act like he did at the end of this story?" "do you believe ana could have behaved differently to change the outcome of this story?" "do you believe ana got what she deserved?" "do you believe ana could have prevented what happened at the end of this story?" and "do you think that ana's behavior provoked what happened at the end of this story?" the scale response format was a 7-point likert-scale form, with responses ranging from (1) strongly disagree to (7) strongly agree. higher scores indicated more blame attributed to the victim. there was strong internal consistency in the present study (cronbach's α = 0.81). all analyses were conducted using spss (statistical package for the social sciences version 26.0, ibm corp., armonk, ny, usa) software. to evaluate the effect that experimental manipulation (control, prescription drug and alcohol) has on victim blaming, one-way anovas with welch's test procedure was conducted. additionally, pairwise comparison tests were used to examine descriptive data. regarding the anova for victim blaming with the different conditions (control, psychotropic prescription drug and alcohol), levene's test for heterogeneity of variance indicated that responses to victim blame questionnaire violated the homogeneity of variance assumption (f (2, 133) = 10.59, p < 0.001). accordingly, we conducted welch's test procedure [58] . welch's test held a significant effect f welch (2, 80.63) = 5.62, p = 0.005 (see table 1 ). our results confirmed hypothesis 1, and pairwise comparisons indicated that participants who read the alcohol abuse scenario scored higher on victim-blaming compared to the control condition (t (59.97) = −3.19, p = 0.002). however, results did not confirm hypothesis 2, and there were no significant differences on victim-blaming among participants who read the psychotropic prescription drug abuse scenario and the control scenario (t (78.56) = −1.78, p = 0.08). means are presented in table 1 . results did not yield a significant effect of the psychotropic prescription drug on the blame attribution to the victim. there was, however, a clear tendency among participants to attribute a higher blame to women who have a prescription drug problem compared to the control condition. victims of intimate partner violence are targets of a double source of blaming, namely: the social judgement about their victim status and their own perception of their responsibility of such violence. results from the first study showed the importance of victim's alcohol consumption on victim blaming among general population; the second study aims to explore the effect that alcohol and prescription drug use have on the victim's self-blaming and self-blaming cognitions. the study entitled "alcohol and prescription drug consumption and its effect on interpersonal relationships" was approved by the institutional ethical committee of loyola university previous data collection and participants were recruited from an online survey. inclusion criteria were: (1) self-identifying as a woman, (2) being older than 18, (3) currently in a heterosexual relationship, (4) correctly answering two attentional checks and (5) the woman abuse screening tool (wast-short): this tool was utilized to evaluate the inclusion criteria of self-identifying as victims of ipv. the spanish-language version of this scale has shown good specificity (76.2%) and good sensitivity (91.4%) [59] . the wast-short is composed of two items that assess the degree of relationship tension and the difficulty that the couple reports in solving arguments on a scale from 1 (no tension/no difficulty) to 3 (a lot of tension/great difficulty) [60] . following plazaola-castaño et al. [59] a response of 2 or 3 on any of the two items was coded as positive (1) whereas a response of 1 was coded as negative (0). the total score, calculated by summing both items, ranges from 0 to 2, with 2 being the cutoff (participants scoring 0 or 1 were excluded). consequently, participants in the study included those experiencing some or great difficulty and some or a lot of tension on their relationship. this way of calculating the final score is the recommended for spanish population [59] . the alcohol use disorders identification test (audit) [61] is a 10-item self-report screening measure assessing alcohol use disorders (aud) and harmful alcohol use. the current study utilized the total score to measure alcohol use problems, with a cut-off of 7 points for problem drinking as suggested by babor and collaborators [62] to be used by women. there was strong internal consistency in the present study (cronbach's α = 0.81). prescription drugs: in the absence of an existing validated measure of the extent to which participants use prescription drugs, we adapted four items from a larger measure used by antich and collaborators [63] . specifically, we asked participants: "have you ever taken psychotropic prescription drugs for depression, anxiety or sleep disorders?" with a response format including 0 (no consumption) or 1 (consumption). two participants have missing data in this question. among participants reporting any psychotropic drug use, three different questions were presented to explore the length of time that they had been using prescription drugs for (a) depression, (b) anxiety and (c) sleep disorders. with this purpose, a likert scale was used with responses including 1 (less than 1 month), 2 (from 1 to 3 months), 3 (more than six months) and 4 (more than one year). the final timeframe of prescription drug consumption was the average of the time reported for depression, anxiety and sleep disorders (m = 2.43; sd = 1.04). this result indicates that among participants who reported any prescription drug use, they had done so for between three and six months in average. a total of eight responses were coded as missing on these two measures because of the inconsistent responses of participants to the items (e.g., reporting no previous psychotropic prescription drug use in the first question but then providing details on the specific features of their prescription drug use). self-blame: in order to evaluate the self-blame that women feel as a consequence of being victims of interpersonal violence, the combination of two instruments was used. firstly, the items of the psychological violence (e.g., my partner demands obedience to his whims) from the reduced spanish version of the index of spouse abuse were used (isa) [64] , and afterwards, the level of self-blame that female participants felt towards these items was assessed. secondly, we listed the items referring to behaviors of physical violence (e.g., my partner becomes abusive when he drinks) from the isa scale and immediately asked participants about the level of self-blame regarding those items. specifically, after reading the items on physical or non-physical violence, we asked participants: "how guilty do you feel?". the response format is a 6-point likert ranging from 0 (not guilty) to 5 (totally guilty). we calculated the total score by averaging the score reported for both items. there was strong internal consistency of this measure in the present study (cronbach's α = 0.85). self-blame cognitions: the subscale from the posttraumatic cognitions inventory (ptci) [65] was translated (and back-translated) into spanish and adapted for the study purpose. self-blame subscale is a self-reported measure to assess self-blame as part of the traumatic cognition, and it was adapted to evaluate female perception of having acted wrongly with regards to the violence they have experienced (e.g., "it happened because of the way i acted"; "it happened to me because of the sort of person i am"). the response format is a 7-point likert from 1 (totally disagree) to 7 (totally agree). the total score was calculated as the mean of the five items [66] . there was strong internal consistency in the present study (cronbach's α = 0.87). the self-blame questions of the trauma questionnaire were presented immediately after the items from the reduced spanish version of the index of spouse abuse [64] . the self-blame cognition subscale was adapted in order to ask participants to answer these questions with regards to the victimization items they had just read. independent samples t-tests were conducted for testing hypothesis 3, predicting significant differences on self-blame (hypothesis 3a) and self-blame cognitions (hypothesis 3b) depending on their alcohol problematic consumption. to test hypothesis 4, which predicts that alcohol consumption will predict self-blame (hypothesis 4a) and self-blame cognition (hypothesis 4b) among ipv victims, regression analyses were run to evaluate the predicting role of self-blame and self-blame cognitions on alcohol use. to test hypothesis 5, which predicts differences on self-blame (hypothesis 5a) and self-blame cognition (hypothesis 5b) among ipv victims depending on their prescription drug use, independent samples t-tests were conducted. lastly, in order to test hypothesis 6, predicting a relation between prescription drugs use duration and self-blaming (hypothesis 6a) and self-blaming cognitions (hypothesis 6b), correlation analysis between drug use duration and both measures of self-blaming were conducted. tables 2 and 3 . hypothesis 3, which predicts higher self-blame (hypothesis 3a) and self-blame cognition (hypothesis 3b) on ipv victims with an alcohol abuse problem, is partially supported (see table 3 ). in accordance with hypothesis 3a, female participants who reported having problematic alcohol consumption scored higher on self-blame (t (43.26) = −2.22, p = 0.03). women scoring above the alcohol problematic cutoff scored higher on self-blame (m = 0.81, sd = 1.31) compared to women below the cutoff (m = 0.31, sd = 0.81). however, and contrary to hypothesis 3b, female participants who reported having a problematic alcohol consumption did not report higher self-blaming cognitions (t (177) = −0.99, p = 0.33) (see table 4 ). note: * p < 0.05, significant difference; the difference in sample size is due to missing data on some scales. our results confirmed hypotheses 4a and 4b, since higher alcohol consumption was related to higher self-blame (b = 0.22, t = 2.97, p = 0.003) and self-blame cognitions (b = 0.17, t = 2.23 p = 0.03) (see table 5 ). finally, our results did not allow us to confirm hypotheses 5a and 5b (see table 4 ). there were no significant differences between female participants on their self-blame (t (175) = 0.09, p = 0.93) and their self-blame cognitions (t (173) = −1.53, p = 0.13) depending of their prescription drug consumption. moreover and contrary to hypothesis 6, which predicts a positive relation between the prescription drug duration and self-blame (6a) and self-blame cognition (6b) among ipv victims, there was not a significant association between time consumption of prescription drugs and self-blame (r = 0.13, p = 0.27) and self-blame cognitions (r = −0.04, p = 0.71) reported by victims of intimate partner violence. the present work examined the effect of alcohol and prescription drug use on victim-blaming. particularly, we have focused on female victimization since the world health organization report [3] states that women are frequent targets of violence, whereas men are more likely to be perpetrators. moreover, social perception in intimate partner violence phenomena is determinant [67] . with these considerations in mind, the present study had two goals in different populations. firstly, we examined the social perception of victim-blaming depending on the victim's alcohol or prescription drug abuse. secondly, and focusing on intimate partner violence victims, we evaluated whether the reported consumption of alcohol and prescription drugs would be related to self-blame and self-blaming cognitions. study 1 revealed that presenting an alcohol abuse problem but not a prescription-drug abuse problem was related to higher victim-blaming compared to a control condition among general population. this result might be explained because women who use alcohol are considered to violate social gender norms, whereas prescription drug abuse is in accordance with the stereotypical view of women as emotionally weak [26] . this result replicates previous studies reporting that "drinking by domestic violence victims would lead to increased victim blame and derogation" [45] (p. 1054) because alcohol consumption has a detrimental effect on the attribution of empathy and compassion. alcohol abuse causes women to be perceived as behaving inappropriately, which decreases the perpetrator's attribution of blame and increases the female's responsibility of the violence [68, 69] . from the perspective of the just world theory [70] , which states that bad things happen just to bad people and people who deserve it, victim blaming in intimate partner violence situation is one of the strategies that allow people to believe that the world is a just and fair place [71] . valor-segura, expósito and moya [72] found that people who endorse to a higher extent the belief in a just world attribute higher victim-blaming to the victim when there is not a cause for the violence, because people tend to think that the victim must have done something to deserve such violence. our experimental manipulation gave participants a pretext to attribute blame to the victim, i.e., she has an alcohol problem. moreover, the current work extends previous literature revealing that there are no differences on victim blame associated to the victim's psychotropic prescription drugs abuse problem. this result might be explained because the stereotype of women abusing prescription drugs would be that of weakness and overemotional among other characteristics [73] , which is in accordance with the submissive stereotypical position hold by intimate partner violence victims. this result is in line with findings from little and terrance [74] , supporting that female victims described as more feminine are considered less blameworthy. merging results from capezza and arriaga [31] and the findings presented here, we can assert that women with an alcohol abuse problem are violating their gender role, and turning into higher victim-blaming in case they experience ipv violence. does social stigma towards female victims of ipv with alcohol abuse problem affect their own perception and attitudes toward the violence they experience? based on the fact that women with substance abuse problems perceive lower levels of social support in the context of ipv experiences [75] , we hypothesized that among victims of ipv with higher drugs and alcohol consumption, the internalization of social blaming would be higher compared to ipv victims with lower substance use. with this goal in mind, the second study using a specific sample of ipv victims aimed to explore the effect that alcohol and prescription drugs have on self-blaming attribution for the violence they had experienced. results of study 2 concluded that victims with higher alcohol consumption or an alcohol use disorder endorse submissive and self-blaming beliefs. this result is in line with previous studies indicating that victims of intimate partner violence with addiction problems have a lack of personal autonomy [76] . this result is highly relevant because alcohol abuse is significantly higher among those women who have experienced intimate violence compared to non-victims [77] . if experiencing violence is a risk factor for alcohol abusive problem, and this abusive behavior leads to self-blaming among ipv victims, self-blaming is a perpetuating phenomenon among women who use alcohol as a coping strategy for ipv situations. according to the trans-theoretical model, self-blaming cognitions and feelings might contribute to the victims' emotional distress and hinder victims' progression through the ttm-based stages. the use of alcohol by ipv victims might aggravate this situation. moreover, it might be that alcohol consumption is used by female victims as a way of enhancing the bond with their partner [78] , given the high emotional dependence on their partners [79] . another alternative is that their perception of lack of mate alternatives because of their addiction would decrease their readiness to leave the abusive relationship [78, 80] . this might in turn increase their self-blame for not leaving the abusive relationship. lastly, another alternative is that self-blaming cognitions might be explained because women are aware that they are violating the gender norm due to their alcohol consumption. this perception comes from social stigmatization to female drinkers [81] . however, they would not be aware of such violation if they use psychotropic prescription drugs since its consumption is perceived as normalized and harmless, because they might be prescribed by a doctor [82] . despite the significant findings in our study about the role of alcohol and prescription drugs use on blame and self-blaming attribution among ipv victims, this study is not without limitations. firstly, the current studies focused solely on one side of the phenomenon. while gender violence is a gendered phenomenon where women are mostly victims and men are perpetrators of the violence, it would be important to evaluate the level of male alcohol consumption to control for relations found between self-blaming and alcohol consumption in study 2. secondly, the manipulation in the first study has been carried out through a scenario method, which might have limitations regarding external validity. additionally, it was carried out with a convenience sample, and the level of victimization or perpetration of participants was not evaluated. even though this level of victimization should be randomly distributed across the three conditions, future studies should explore the role of experiencing violence on victim blame attribution. thirdly, the correlational nature of study 2 avoids any interpretation of causality. accordingly, longitudinal studies should be conducted that examine the long-term and reciprocal associations between ipv victim blaming on alcohol and prescription drugs use. fourthly, the use of different samples for each study compels us to be cautious regarding the interpretation of possible relationships between studies. further studies should evaluate both the effect of contextual and internal variables in the same sample of ipv victims and their social network. fifthly, previous research indicates that variables such as depressive symptoms [83] or dysphoric symptoms [84] might also have a significant impact on self-blame and self-blaming cognitions. in our study, and due to time limitations, no further information was collected on possible control variables. results from ols regression should then be interpreted with caution. finally, an important limitation of the second study is the use of the wast. in our study, we have used the criterion scoring for spanish population to create the cut-off recommended by plazaola-castaño et al. [59] due to its higher sensitivity. we must note though that this cut-off level has been shown to detect a high number of false positives, meaning that some of the women who are considered as battered by the instrument might be erroneously classified as such. however, in our study, we are not particularly interested in an exhaustive detection of intimate partner violence, and our interest is to analyze the effect of alcohol and prescription drug use on self-perception among women experiencing any kind of violence. this investigation is designed as a potential contributor to the attainment of the fifth goal of the sustainable development goals (sdg) adopted by the united nations member states, which aims to achieve gender equality and empower all women and girls. specifically, we have adopted a dual approach that integrates social and individual perspectives on the victim's blame attribution analysis. this allows us to attain a comprehensive understanding of the role of alcohol and drugs on victim blaming that contributes to expand our knowledge on the role of victim's behaviors on attributions. in particular, results revealed that alcohol consumption, but not prescription drug consumption, increases blame attribution among observers and self-blame attribution among victims. both results are closely related because of the fact that people perceive women with an alcohol abuse problem as responsible for the violence they experience, it is manifested in everyday discriminant and non-helping behavior [85, 86] causing the victim to internalize such blame. present findings and future studies in this line of research have implications for interventions with victims who are alcohol users and for policy intervention. on the one hand, the consideration of blaming attribution and self-attribution is crucial for mental health professionals working with ipv victims, since self-blame moderates the relation between physical abuse and ptsd severity [36] . drinking problems on 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acceptance, gender role conformity and substance use on victim blaming violent victimization among women with alcohol problems. in recent developments in alcoholism: alcoholism and women; recent developments in alcoholism family violence and covid-19: increased vulnerability and reduced options for support world health organization. mental health and covid-19; world health organization collision of the covid-19 and addiction epidemics the authors acknowledge the collaboration of maría ruiz (m.r.) who was involved on data collection of the first study, and ayan ahmed (a.a.) for proofreading. the authors declare no conflicts of interest. key: cord-000266-xwfptmmv authors: liao, qiuyan; cowling, benjamin; lam, wing tak; ng, man wai; fielding, richard title: situational awareness and health protective responses to pandemic influenza a (h1n1) in hong kong: a cross-sectional study date: 2010-10-12 journal: plos one doi: 10.1371/journal.pone.0013350 sha: doc_id: 266 cord_uid: xwfptmmv background: whether information sources influence health protective behaviours during influenza pandemics or other emerging infectious disease epidemics is uncertain. methodology: data from cross-sectional telephone interviews of 1,001 hong kong adults in june, 2009 were tested against theory and data-derived hypothesized associations between trust in (formal/informal) information, understanding, self-efficacy, perceived susceptibility and worry, and hand hygiene and social distancing using structural equation modelling with multigroup comparisons. principal findings: trust in formal (government/media) information about influenza was associated with greater reported understanding of a/h1n1 cause (β = 0.36) and a/h1n1 prevention self-efficacy (β = 0.25), which in turn were associated with more hand hygiene (β = 0.19 and β = 0.23, respectively). trust in informal (interpersonal) information was negatively associated with perceived personal a/h1n1 susceptibility (β = −0.21), which was negatively associated with perceived self-efficacy (β = −0.42) but positively associated with influenza worry (β = 0.44). trust in informal information was positively associated with influenza worry (β = 0.16) which was in turn associated with greater social distancing (β = 0.36). multigroup comparisons showed gender differences regarding paths from trust in formal information to understanding of a/h1n1 cause, trust in informal information to understanding of a/h1n1 cause, and understanding of a/h1n1 cause to perceived self-efficacy. conclusions/significance: trust in government/media information was more strongly associated with greater self-efficacy and handwashing, whereas trust in informal information was strongly associated with perceived health threat and avoidance behaviour. risk communication should consider the effect of gender differences. pandemic influenza a/h1n1 has a clinical profile similar to seasonal influenza, despite initially appearing more severe [1] . respiratory infectious diseases (rids) such as influenza are a major public health issue best dealt with by prevention, ideally vaccination. however, in the first six-months or so of a newlyemergent rid epidemic/pandemic vaccines are generally unavailable and non-pharmacological interventions can play a major role in minimizing rid spread [2] [3] [4] . government health education messages are a major source of information for promoting self-protective practices against rids. these preventive messages generally emphasize improved hygiene, face-mask use by infected persons, and social distancing measures, including avoiding crowds during epidemics [5] [6] [7] . predictors of population uptake of health protective behaviours in rid epidemics have begun to be studied [8] [9] [10] [11] [12] [13] , yet related theory remains nascent and this is problematic: to effectively predict behaviour during future epidemics robust theory is critical. effective models that enable comprehensive prediction of health protective behaviours remain limited mainly to two overlapping theoretical paradigms: the theories of reasoned action/planned behaviour (tpb) [14] [15] [16] and bandura's concept of self-efficacy [17] [18] [19] (the belief that one can successfully execute some behaviour), particularly regarding the core tpb concept of perceived behavioural control, which controversially is claimed by some to be largely synonymous with self-efficacy [19] [20] [21] and by others to be indistinguishable from intent [22] (the intention to execute a particular behaviour), the key predictive element of tpb [16] . when used to account for health-related behaviours tpbbased models typically account for ,35% of variance in outcomes [16] , while self-efficacy accounts for ,25% of variance in outcomes [23, 24] . however, neither tpb nor self-efficacy allow for the social and affective influences that might be expected logically to be important in rid [25, 26] . we report on a theoretical model that incorporated elements of influenza causal knowledge, perceived self-efficacy and also social and affective influences ( figure 1 ) because these latter variables have been less frequently studied in combination, but have theoretical and logical support for their potential importance in the context of rids. we tested this model against data collected in the early phase of the influenza a/h1n1 pandemic (table s1 ) to examine how levels of trust in formal and informal sources of risk/prevention information associated with hand washing and social distancing. ethics approval was obtained from the institutional review board of the university of hong kong/hospital authority hong kong west cluster. for this telephone interview, written informed consent was waived by the irb but verbal consent was required from all the respondents and agreement to participate in the interview was taken as further consent. before the interview began, a brief introduction about the study aims and interview contents was given and then respondents were asked whether the interview could start. if approval was received this was recorded and the interview performed. if not, respondents were thanked and the call was terminated. more than 98% of hong kong households have landline telephones and all local calls are free. random-digit dialled telephone numbers and within-household random-sampling grids (kish grids) are a cost-effective way to survey highly representative random population samples. kish grids are matrices containing random numbers for different sized households that facilitate random selection of individuals within households and help minimize sampling bias. the number of eligible household residents, ''n'', is determined by asking the person of first contact in the household. the kish grid provides a randomly generated number ''k'' between 1 and ''n'' which is used by the interviewer. ordering by age and starting from the oldest eligible member in the household, the k'th member is then invited to participate in the survey. different grid values are used for each household. as part of a series of surveys to monitor a/h1n1 epidemic activity, a commercial polling organization administered the questionnaire using this telephone-survey methodology, targeting 1,000-1,500 participants on each occasion, a sample size calculated to give an estimate of a/h1n1 health protective behaviours with a precision of 63%. the survey with the largest sample was selected for this analysis. sampling was performed during the evening to minimize exclusion of young working adults. data on attitudes, knowledge, situational awareness, risk perception and preventive behaviours (table s1) were collected by household telephone interviews, based on random digit dialling. one cantonese-speaking adult (age$18) who lives .4 nights per week in each household was selected using a kish grid. all interviews were conducted between 8:30pm-10:45pm from 23 rd -25 th june, 2009, two weeks after the first community transmission had been identified in hong kong. existing theoretical frameworks of behaviour change have been adapted to predict health-related behaviour-change for chronic, non-communicable diseases [15, 16] , but we lack a comprehensive evidence-based model of protective behaviour against rid threat [11] . a recent review of 26 papers on rid prevention behaviours concluded that 23 lacked a theoretical basis [13] . existing applications of health behaviour change models in communicable disease are almost exclusively limited to hiv/aids research [24, 27] and to a lesser extent hepatitis b and c, which share the same transmission pathways as hiv. there are good reasons why sexually-transmitted diseases embody a different set of influences than do rids. for example people are highly motivated to seek sexual contact (or injection drug use) and have a high degree of potential control (e.g. condom use) over the nature of these encounters, even though they may be situationally constrained from executing that control, and are infected only by direct exchange of bodily fluids. in contrast, one can acquire an rid transmitted by air droplets, hand contact or fomites for up to 72 hours after the person who is the source departs [28] , or immediately by being sneezed on. infection is much more casual. clearly, the controllability of rids requires different behavioural imperatives to those in stds and hence different psychological influences should be considered. attempts by the tpb to accommodate social influences had relied on incorporating social norms [14] , the behavioural expectations within a group. however, norms, and hence theoretical models reliant on norms to account for social processes, cannot accommodate the fact that communicable respiratory diseases make other humans ambiguous sources of threat: one can usually control sexual encounters but not who shares public transport. in this respect social factors in communicable respiratory disease differ significantly from those in non-communicable diseases and warrant greater consideration than existing hbc models allow. outbreaks of new infectious diseases constitute situations that are uncertain, dynamic, and embody highly personal threat, requiring rapid decisions on appropriate action [29] . under such circumstances timely and relevant information on the best preventive actions become critical to such decision-making. hence, health protective behaviour during the early stages of a novel epidemic would be more likely to resemble situational reactions using established or known default actions such as avoiding crowds (social distancing), rather than intention-based planning before any behavioural change, such as deciding to consult a doctor to administer a vaccination. later in the epidemic as threat familiarity increases, different factors such as planned behaviour may become important. reporting delays, uncertainty and other biases affect publicly available information on the characteristics of newly-emergent communicable diseases, such as a/h1n1 lay knowledge of infection-related risks can be limited. the resulting uncertainty about disease severity and transmissibility at the epidemic onset extends to the utility and timing of adopting preventive measures. information cues to individuals about initiating protective action must therefore be synthesized from various sources. perceived information reliability or trustworthiness influences decisions to utilize any given information source [30] to inform awareness of the situation. more trustworthy sources are therefore likely to be more influential. epidemic situational awareness is likely derived from formally-announced public information like news items, government press releases and health education messages, and also from informal, social sources [25, 29] ; observation of other peoples' behaviour and communications from family, peers and neighbours. noting how others behave informs action decisions in the observer [19] . if those around you are wearing masks, this indicates others might have knowledge you do not possess, and that the threat level might be locally high and imminent, suggesting prudent precautionary or rid preventive behaviour. observers are also subject to social conformity influences that can help adoption of group patterns of behaviour. maintaining situational awareness, involving elements of perception, comprehension and prediction [31] , during epidemics probably relies on these two types of information. however, when uncertainty is high and widespread, or when there is low confidence in social and other information sources then individuals' hpbs might be expected to be more independent of formal and informal information sources. perceived risk is influenced by several stimulus characteristics, including unfamiliarity, invisibility, dreadfulness and inequity [32] , and by recipient characteristics, including demographics and trust in information source and content [33] . perceived risk is an important determinant of protective behavioural responses [12, 34, 35, 36] , but is subject to optimistic bias, where for example people distort their risk of contracting influenza downwards relative to others [35, 37] . nonetheless, susceptibility to risk remains an important measure in understanding variation in behavioural responses to threat and reflects the key element of perceived risk in an epidemic/pandemic situation. worry is a cognitive process linked to anxiety [26, 38] and reflects negative affectivity, interacting with perception of susceptibility to risk [26, 39] and may also influence rid protective responses such as social distancing [13] . because data were collected using telephone interviews we had to adapt measures to suit a brief format in order to avoid people hanging up mid-way or providing invalid answers to hurry the interview, a problem encountered with this data collection method. we therefore used parsimonious measure to minimize assessment fatigue and low response rates which threaten representativeness. trust in government/media (formal) information: we asked about respondents' agreement with three statements (table s1 ). responses were made on categorical five-point scales ranging from ''strongly disagree'' to ''strongly agree''. scalability of these three items was assessed using cronbach's alpha, which at 0.61 indicated that the internal consistency between items was low, but acceptable. however, to minimize potential measurement error arising from the low internal consistency, this construct was treated as a latent variable in the subsequent analysis [40] . a latent variable is a concept opposed to an observed variable. a latent variable can not be measured directly but is inferred from one or more variables that are directly measured (observed variable) while an observed variable can be directly measured with a specific question or item or observed by the researchers. for example, an ''attitude'' is a concept that is difficult to measure directly with single items but can be inferred from various questions asking about different aspects of that attitude. then within the analysis ''attitude'' is treated as the latent variable while the questions used to infer it are the observed variables. trust in interpersonal (informal) information: respondents' agreement with two statements (table s1 ). responses were made on categorical five-point scales ranging from ''strongly disagree'' to ''strongly agree''. scalability of these two items was assessed using cronbach's alpha, which at 0.50 indicated that scalabilty was unsuitably low for two items. this suggests that these two items measure different aspects of social information. again to minimize potential measurement error this construct was treated as a latent variable in the subsequent analysis. understanding cause of a/h1n1 (''i understand how swine flu is caused'') and self-efficacy (confidence in one's ability to act in a way that achieves desired future outcomes) for a/h1n1 prevention (''i am confident that i can protect myself against swine flu''): each was assessed using responses on 5-point scales of agreement with these two single item statements (table s1) . perceived personal susceptibility: two items, one assessing absolute susceptibility (perceived absolute probability of developing a/h1n1) and another assessing relative susceptibility (perceived probability of developing a/h1n1 relative to peers) formed a latent variable for perceived personal susceptibility (table s1 ). the cronbach alpha of these two items was 0.66. worry about contracting h1n1. respondents were asked to indicate their level of worry over the past one week about contracting influenza a/h1n1. responses were 5-point scales of worry ranged from ''never thought about it'' to ''extremely worried'' (table s1 ). hand hygiene. respondents were asked to indicate frequencies of use of four hand hygiene practices over the three days prior to interview: hand washing after sneezing, coughing and touching nose; hand washing after returning home, use of liquid soap for hand washing, and hand washing after touching common objects. responses were on a 4-point scale of frequency: 1 ''never'', 2 ''sometimes'', 3 ''usually'' and 4 ''always''. cronbach's a was 0.62 (table s1 ). social distancing behaviours: a. social avoidance. respondents were asked to indicate if they had adopted any of four avoidance behaviours due to influenza a/h1n1 in the past 7 days: avoiding eating out, avoiding using public transport, avoiding going to crowded places, and rescheduling travel plans responses were coded as 1 ''yes'' and 0 ''no''. cronbach's a was 0.61 (table s1 ). we first compared the demographic structure of the sample against that of the general population derived from the hong kong government general household survey to identify any sample differences. our model proposes that trust in formal (government and media sources) and informal (from other people) information affects rid epidemic health protective behaviours, the former by informing about generic risk and response characteristics for dealing with a potential threat (causes and protective responses), the latter about threat imminence, severity and response effectiveness (seeing how others behave). we refer to the product of these combined processes as situational awareness, and propose that rather than driving behaviour directly information acts through altering the cognitive/affective domain of situational awareness. thus the model is predicated on several premises: that understanding of the disease and perceived personal susceptibility influence self-efficacy [17, 18, 31] ; that the effect of perceived susceptibility to influenza on hpbs acts through increasing worry about the disease [26, 33, 38, 41, 42] ; and that more worry from perceived susceptibility prompts hpbs [39, 41, 42] . these cognitive/affective processes are represented in the hypothesized model ( figure 1 ). structural equation modeling (sem) is a method for simulating and testing multiple and interrelated causal relationships simultaneously in statistical data, making it suitable for theory development and testing [40] . sem was applied to test the hypothesized model. sem is usually performed when a model contains latent variables assessed with specified measurement models. despite including estimations of a series of multiple regression equations, sem differs from regression analysis in several ways, which make it advantageous for this kind of analysis. first, sem is usually theoretically based because it is performed after researchers specify the hypothesized model. second, it can be used to refine the hypothesized model by estimating the measurement model and structural model simultaneously. finally sem analysis can accommodate measurement errors of the constructs in the model [40] . in our hypothesized model, trust in formal information, trust in informal information, perceived personal susceptibility, hand washing and social distancing behaviours were entered as latent (inferred) variables while other constructs were entered as observable (directly measured) variables because they were assessed with only one item. two different health protective behaviors, hand washing and social distancing, were entered as the hpb outcomes because we hypothesized that different influences may act on each of these. we assumed that the ''disturbances'' of the two health behavior outcomes were correlated. disturbance represents the unexplained variances of the latent variables predicted by the specified independent variables [40] . in making this assumption, we assumed that unexplained variance in the outcome variables could be correlated and the variables in question jointly influenced by other unknown factors, and so allowed for such constraints within the model by using more conservative criteria. previous studies have shown that hand hygiene and social distancing behaviours during a pandemic could be influenced by some common causes which were not fully explored in our study such as current health, past experience of disease and cues to action [14] . in particular, in our study, the two kinds of health protective behaviours occurred in the same situation of the 2009 influenza pandemic, and so it is sensible and reasonable to assume that they could be influenced by some common causes which were not fully explored in our studies. adequacy of the measurement models was tested before testing the full structural model. to test the full structural model, all constructs ( figure 1) were entered into the model and all factor loading, specified paths, covariance, measurement errors and disturbances were estimated simultaneously. since the model contained categorical variables, weighted least square with mean-and variance-adjusted estimation (wlsmv) was used to estimate the standardized parameter (b) for each path [43] . with this kind of estimation, chi-square difference testing is inappropriate. we therefore used the comparative fit index (cfi), tucker-lewis index (tli) and root mean squared error of association (rmsea) to evaluate the model fit to the data. a cfi.0.95, tli.0.95 and rmsea,0.05 indicate a good fit of data to the model [43] . the analysis was conducted in mplus 6.0 for windows [43] . the proportion of missing values ranged from 0.1% for ''in the past one week, have you ever worried about catching influenza a/h1n1'' to 10.1% ''did you wash hands after sneezing, coughing or touching nose in the past 3 days''. missing data were handled with multiple imputation to generate 10 datasets which were summarized into one for subsequent analysis. multiple imputation was performed in ameliaview [44] . responses are likely to differ by sociodemographic factors [13] . we therefore stratified the sample by gender and by age (,45 years old vs. .45 years old). education is also likely to have a significant effect but there are difficulties in education stratification in hong kong. the age cut-off of 45 years was adopted to account for the introduction in hong kong of 6-year compulsory education in 1971 and 9-year compulsory education in 1978 [45] . this means that people aged 45 or above are much less likely to have a tertiary (college/university) level education and less secondary (high school) education than people aged ,45 years old [45] . moreover, in traditional families in china, a son (who lived with his parents after marriage) was usually more educationally-favoured over daughters (who moved to their in-laws' home on marriage) to ensure support for the parents in their old age, so males usually obtained more education than females [45] . these distinctions were somewhat evidenced by our data which showed that 98% of the respondents aged ,45 compared to 71% of the respondents aged 45 or above (x 2 = 147.69, p,0.001), and 89% of male compared to 80% of female respondents, obtained at least secondary education (x 2 = 17.05, p,0.001). since the numbers of tertiary educated respondents and primary (elementary) educated respondents were too small to produce stable models, we limited stratification to gender and age only and acknowledge that this also incorporates indefinable education and income effects. consequently, we used a multi-group sem to assess the invariance of the model (figure 1 ) across gender and age group (respondents aged 18-44 and aged 45 or above). we tried to test the model by stratifying the sample into four subgroups (female aged 18-44, female aged 45 or above, male aged 18-44 and male aged 45 or above). however, the sample size for males aged 18-44 was relative small (table s2) . moreover, all the model variables were treated as categorical variables and we used the wlsmv method to estimate the model. this method requires that each subsample covers all the categories of each variable. in the case of one category, younger males, not all variable values were present. to meet the assumptions for analysis we would need to recode all variables, intrinsically altering the model. in order to avoid this, we relinquished a combined four-group comparison and instead compared the model across gender and the two age groups separately. to perform multigroup comparison we first ran a model with all parameters unconstrained. we then identified factor loadings that were not significantly different (p$0.05) and set these as equal, while loadings that were significantly different were allowed to vary, and finally paths that did not differ significantly were constrained to be equal while those that differed significantly were allowed to vary and estimated separately by groups. the ''difftest'' option in mplus 6.0 was used to obtain a correct chi-square difference test for the wlsmv estimators and was used to estimate the differences between the least constrained model (with all the paths freely estimated) and the most constrained model (with all the paths constrained to be equal) as well as the partially constrained model (with some of the paths freely estimated and others constrained to be equal) [43] . a p-value.0.05 for the ''difftest'' indicate a nonsignificant difference between the models. finally, to help interpret these multigroup sem comparisons, we performed a post-hoc examination of the model variable means for different gender and age groups and tested differences using the mann-whitney test, which tests differences between two groups on ordinal scales of measurements. a total of 1,001/1,449 (69.1% response rate) hong kong adults successfully completed the interview. the characteristics of the sample were compared against the hong kong 2006 by-census population data [46] , showing respondents to be better educated and more likely to have been born in hong kong compared to the general population (table 1 ) but otherwise representative. both formal and informal information trust were correlated with all situational awareness variables except worry about contracting a/h1n1 (''worry''), while formal information trust was also independent of perceived personal susceptibility (''susceptibility''). in turn, understanding of h1n1 cause (''understanding'') and perceived self-efficacy (''self-efficacy'') were significantly associated with hand washing while worry and susceptibility were significantly associated with social distancing (table s3 ). the sem model fitted well to the data with cfi = 0.977, tli = 0.969 and rmsea = 0.026. standardized coefficients indicated two primary features in the model; the first one linking formal information and hand hygiene and a second linking informal information and social distancing ( figure 2 ). paths were seen via formal information trust and self-efficacy (b = 0.25) and self-efficacy and hand hygiene (b = 0.23), and via formal information trust and understanding (b = 0.36), and understanding and hand hygiene (b = 0.19) while understanding and selfefficacy were independent. these associations formed the first feature. marginal associations between worry and hand hygiene and between self-efficacy and social distancing were seen, but the small standardized coefficients of b = 0.13 suggest that these paths are minor. susceptibility and worry were associated, but otherwise were functionally independent, both upstream from formal information trust, and downstream from hand hygiene. the second feature of the model is reflected in a different set of paths associating informal information trust with social distancing. trust in informal information sources was inversely associated with susceptibility (b = 20.21), which was associated positively with worry (b = 0.44), and inversely with self-efficacy (b = 20.42). however, more confidence in informal information sources was associated with more worry (b = 0.16) and finally, only worry was associated with social distancing (b = 0.36). trust in informal information was independent of understanding and self-efficacy. the only remaining notable feature of the model was a strong inverse association (b = 20.42) between susceptibility and selfefficacy. this suggests some interaction between these two variables that could strongly influence both sets of paths mentioned so far. overall, the model explained 11.3% of the variance in hand hygiene and 16.1% of the variance in social distancing behaviors. across gender, both the least constrained model and the most constrained models fit the data well with cfi.0.970, tli$0.970, rmsea = 0.025. the most constrained model did not differ significantly from the least constrained model (x 2 for ''difft-est'' = 29.30, d f = 19, p = 0.061). however, three sets of associations differed significantly between females and males: those between formal information trust and understanding, from informal information trust to understanding, and from understanding to self-efficacy. these paths were set free and estimated separately in female and male. the model with these paths freely estimated fit well to the data with cfi = 0.978, tli = 0.976 and rmsea = 0.023, and did not differ significantly from the least constrained model (x 2 for ''difftest'' = 15.07, d f = 16, p = 0.519). figure 3 presents the results of multigroup comparison of the model applied to males and females with the three path parameters unconstrained. for a given path, if the path coefficients did not differ significantly between males and females, only the path coefficient for males is presented; if the path coefficients differed significantly between males and females, the path coefficients for both genders are presented with the coefficients for males presented on the left of the slashes and for females presented on the right of the slashes. by comparison, the model shows that for both genders while the association between formal information trust and understanding was positive this association was stronger amongst females (b = 0.50) than males (b = 0.25); the association between informal information trust and understanding was weakly positive in males (b = 0.12) but weakly negative in females (b = 20.14), and; the association between understanding and self-efficacy was positive (b = 0.12) in males but non-significant in females (b = 20.01). across the two age groups, both the least constrained model and the most constrained model fit well to the data with cfi.0.960, tli$0.950, rmsea#0.030. the most constrained model did not differ significantly from the least constrained model (x 2 for ''difftest'' = 15.85, d f = 19, p = 0.667). no path was found to be significantly different between the two age groups. means and standard deviations for all model variables by gender and age group showed differences (table s4 ). all the constructs did not differ by gender except for hand hygiene and social distancing with female being more likely to wash their hands and adopt social distancing behaviours. trust in formal and informal information sources, self-efficacy, and hand hygiene significantly differed by age groups, with respondents of older age group being more likely to trust the information from both sources, perceive higher self-efficacy and wash their hands. we tested a hypothesized model of associations between trust in (formal/informal) information, situational awareness variables (causal understanding, self-efficacy, susceptibility and worry) and different types of health protective behaviours (hand hygiene and social distancing) for influenza protection. the model suggested that two different sets of influences relate trust in information to hand hygiene, and to social distancing respectively. the strongest associations observed were between susceptibility and self-efficacy neither age nor gender contributed significant variation to the association between trust in formal information and self-efficacy, and self-efficacy and hand hygiene. these findings are consistent with other studies showing self-efficacy is enhanced by procedural information [18, 19, 47, 48] and that attitudinally and actionoriented interventions are more successful in changing behaviour for communicable disease protection, such as in the case of hiv [24] . similarly, exposure to relevant media stories during the 2009 a/h1n1influenza pandemic was associated with higher efficacy beliefs regarding hygiene, which in turn was associated with greater frequency of reported tissue access and sanitising gel purchase among british people [49] . however, there is evidence that coping style interacts with the ability of procedural information to enhance self-efficacy and under circumstances of high threat, such as during sars-type epidemics where mortality is high, procedural information might be counter productive for some segments of the community who use an information avoidance (''blunting'') coping style [50] . self-efficacy was only weakly associated with social distancing. people are limited in their ability to avoid crowds in hong kong, one of the most densely populated cities on earth, despite the hong kong government recommending this in order to limit the pandemic [51] . however, the relatively mild impact of a/h1n1 meant that people saw no reason to jeopardize their economic well-being and curtail other social activities, given such a low perceived threat [49, 52] . hand washing was probably seen as sufficient protection. the association between trust in formal information and understanding of influenza cause differed by gender but not age, with females showing a stronger association. men tend to have poorer health knowledge than women [53] . we found that females were more likely to wash their hands than were males. older respondents reported significantly greater trust in formal information, marginally-significantly better understanding of influenza cause and were more likely to wash their hands. this is consistent with other studies reflecting that preventive practice is enabled by knowledge of causes [49, 54] . however, increasing knowledge is not itself sufficient to always ensure preventive behaviour [55] . in this context, understanding has an independent contribution to hand washing practice only. trust in informal information seems to be associated with less perceived susceptibility to health threat. this may reflect rational processes or cognitive bias. trusting social cues involves comparison and conformity influences, and can enhance optimistic bias (the tendency to view oneself less likely to experience negative events but more likely to experience positive events) in personal risk estimates [56] , thereby reducing perceived susceptibility. conversely, others' behavioural cues about health threat proximity can arouse motivating worry and anxiety producing protective action [17, 29] . we found trust in informal information was independent of both understanding of influenza cause and self-efficacy. however, when stratified by gender, the trust in informal information-understanding association was positive among males but negative among females. education is probably an important influence in understanding and may have a bearing on these patterns which await clarification. susceptibility was strongly associated with both self-efficacy (negatively) and worry (positively). neither worry nor susceptibility varied significantly by gender or age group. this is plausible and theoretically consistent [26, 34, 35, 39] . worry was strongly associated with social distancing, again consistent with british data [49] . although worry was also significantly associated with hand hygiene, the association was weak. elsewhere, using a generic measure of personal hygiene practices we have found a stronger association between disease worry and hygiene, suggesting a moderate effect of level of disease worry [57] . the model tested explained only a modest proportion of the variance in adoption of hbps, suggesting that there are significant theoretical gaps that remain to be filled. these await further research. social distancing is unassociated with formal hpb messages, suggesting potential susceptibility to a ''herd-like'' response in this chinese community, particularly if confidence in formal (government or doctors) information is low. voerten and colleagues describe such a pattern of response in the early stages of sars [25] . these models support the hypothesis that social distancing is more likely to occur when perceived health threat is high [25] . logically, when others seem to be behaving in a way that is informed and probably consistent then their actions provide clear information. if mixed social messages occur signalling uncertainty then the utility of social information will fall. this is likely to be associated with increase perceived susceptibility, and possibly greater worry and distancing behaviour. this pattern of responses would be most likely early in a novel rid epidemic where disease characteristics and behaviour are often uncertain. high threat uncertainty then drives social avoidance of potentially high-risk others. high levels of worry are associated with greater social distancing. around 50% of 997/14,297 (response rate 7%) british respondents agreed that social avoidance would minimize risk of a/h1n1 infection, and respondents reporting more anxiety were more likely to engage in preventive actions; severity and likelihood of infection were the most important determinants of preventive action [12] . further research on social influences on hpb during epidemic and pandemic rids is warranted. providing more knowledge about disease causes can improve hand hygiene but is unlikely to influence social avoidance, which appears less amenable to formal health messages. however, as formal messages achieve acceptance across the population, and uptake of hpbs increases, then under circumstances where a critical mass of the population are practicing precautions trust in informal information should increase, reducing susceptibility and worry and leading to declines in social avoidance. because others are likely adopting hpbs this makes them less of a contagion risk. conversely maintaining a high level of hand washing practices may require sustained public education activities. finally, different segments of the population probably communicate different types of information with their peers. self-efficacy in preventing a/h1n1 influences hand hygiene but has little influence on social distancing. formal health education messages that focus on enhancing the public's sense of their ability to protect themselves by adopting hygiene practices would seem to be the most effective to improve hand hygiene, but where the practice is already established, high levels of trust in these messages are not likely to significantly increase hand hygiene. this study is limited in being cross-sectional and relying on hypothesized modeling to infer causality. this is potentially errorprone and can only be confirmed by specific longitudinal tests of the hypotheses proposed above. there are potential limitations related to measurement imposed by the need to be parsimonious in questioning due to use of telephone interviews. where this is not done refusal rates would have been unacceptably high [12] raising serious questions about representativeness. as a consequence, construct validity for some latent variables was weaker than expected, for example, only two items were scaled to measured trust in informal information giving a low internal consistency. we re-ran the sem treating the two trust items as separate which gave almost identical associations with different situation awareness variables, so we entered their combined score as a latent variable in the final model. only one item measured self-efficacy. this is generally not considered adequate but does have precedent indicating it is valid for predicting behavioral change [9] . finally, this random sample, closely representative of the population of hong kong and collected early in the epidemic phase, nonetheless was slightly older and less-well educated than the general population. this was likely due to unavoidable sampling bias from surveying in the early evening to 10pm. many young adults do not return home from work until after this time and were thereby not sampled. the results may in part reflect this bias. otherwise the response rate was high at 69% and excellent compared to similar studies [12] . some of these above limitations may also have contributed to the low explained variance of the model. many factors influence rid protective behaviour. this study has examined a very limited number of these. confidence in formal information such as health education messages is associated with greater compliance to recommended preventive measures for influenza a/h1n1 [12] . however, the mechanisms for this were unclear. we have shown that this probably involves different mechanisms for hand washing and social distancing, and suggest how these might function. formal messages may not reduce social distancing behaviours until such time that preventive behaviours are widely adopted in the community. social distancing seems more likely to occur when there is high influenza-related worry and uncertainty, such as in the initial stages when epidemic circumstances are unknown, or if an epidemic is severe and appears poorly controlled, as during early sars. this would seem to be largely worry/affect-driven. if so, then social distancing is likely to occur irrespective of government messages as population anxiety about an epidemic increases. susceptibility may also increase and this may inhibit self-efficacy regarding hand washing. finally, high levels of community uncertainty or rumour are likely to increase distancing by exacerbating perceived susceptibility and worry. a simple version of our findings can be found it the supporting file (text s1). table s1 found at: doi:10.1371/journal.pone.0013350.s001 (0.05 mb doc) text s1 this is 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about colorectal cancer among adults in an area of southern italy knowledge, attitude and practice about sexually transmitted diseases among university students in kampala do moderators of the optimistic bias affect personal or target risk estimates? a review of the literature social-cognitive factors and personal hygiene practices to protect against influenzas: a structural equation model comparing avian influenza a/h5n1 and 2009 pandemic a/h1n1 in hong kong we thank the hku public opinion programme for assistance in administering the telephone survey. we thank dennis ip, angela shen and joseph wu for helpful discussions. we also thank lincoln lau and vicky fang for technical assistance. analyzed the data: ql. wrote the paper: ql. planned the study: rf, bc. key: cord-349371-3htcturz authors: bleakley, alan title: embracing the collective through medical education date: 2020-10-30 journal: adv health sci educ theory pract doi: 10.1007/s10459-020-10005-y sha: doc_id: 349371 cord_uid: 3htcturz the journal advances in health sciences education: theory and practice has, under geoff norman’s leadership, promoted a collaborative approach to investigating educationally-savvy and innovative health care practices, where academic medical educators can work closely with healthcare practitioners to improve patient care and safety. but in medical practice in particular this networked approach is often compromised by a lingering, historically conditioned pattern of heroic individualism (under the banner ‘self help’). in an era promising patient-centredness and inter-professional practices, we must ask: ‘when will medicine, and its informing agent medical education, embrace democratic habits and collectivism?’ the symptom of lingering heroic individualism is particularly prominent in north american medical education. this is echoed in widespread resistance to a government-controlled public health, where the usa remains the only advanced economy that fails to provide universal health care. i track a resistance to collectivist medical-educational reform historically from a mid-nineteenth century nexus of influential thinkers who came, some unwittingly, to shape north american medical education within a protestant-capitalist individualist tradition. this tradition still lingers, where some doctors recall a fictional ‘golden age’ of medical practice and education, actually long since eclipsed by fluid inter-professional health care team practices. i cast this tension between conservative traditions of individualism and progressive collectivism as a political issue. in this article, i engage the reader with a slice of north american medical and cultural history to better understand the present. in particular, i ask why conservative heroic individualism in medicine still lingers in a global, connected age in which medical education's main political role is to democratize medicine. it is only through flattening hierarchies a crude metaphor, but the point is made-that we can authentically realise the twin promises of patient-centredness and inter-professionalism (bleakley 2014) . these sociallyresponsible practices, seeded some decades ago, are often now termed "coordinated care" (langberg, dyhr and davidsen 2019) . i prefer the term 'collaborative care', progressing surface co-ordination of tasks to deeper emotional and values commitment to collaboration as democratic "habits of the heart" (bellah et al. 2008 ). at the point of acceleration of the novel coronavirus pandemic in america, with the death toll nearing 50,000 and rising (at the time of writing it is over 200,000), dr anthony fauci, a distinguished public health expert and the primary medical and scientific advisor in the white house, said of his work: "you stay completely apolitical and non-ideological, and you stick to what you do i'm a scientist and i'm a physician. and that's it" mccarthy, 2020) . in contrast in the uk, also at the height of the coronavirus crisis, richard horton also a doctor, and longstanding editor of the prestigious medical journal the lancetvociferously challenged the uk government's response to the pandemic as too little too late. in an interview with the financial times horton (2020) said, contra fauci: "the idea you can strip out politics from medicine or health is historically ignorant. the medical establishment should be much more politicised, not less, in attacking issues like health inequalities and poor access to care." in an opinion piece in the wall street journal-take two aspirin and call me by my pronouns-stanley goldfarb (2019) , an experienced physician and retired associate dean of curriculum at the university of pennsylvania's perelman school of medicine, complains about 'woke' medical schools where "curricula are increasingly focused on social justice rather than treating illness". 'woke' is invoked here in a disparaging way. it is an african-american term referring to vigilance to acts of discrimination (staying awake, or 'woke') goldfarb's nostalgia for a golden age of medical education supposedly lost to 'woke' interests is badly misguided, as the state of american medicine shows. there is a serious faultline running through american medicine that medical education fails to address. this is the systematic refusal to address upstream community health issues, particularly structural health disparities (inequities and inequalities), focusing instead upon downstream hospitalism unhooked from political concerns. a glaring upstream political issue is that of health care insurance, another is structural racism. stanley goldfarb is not a lone wolf -he represents a reactionary movement in health professions education (hpe) that hankers after a supposed golden age. it is difficult to gauge just how pervasive this movement is, and it may be a generational effect, but my point here is that there is a wider phenomenon at work. prejudice against medical education's potential interest in social justice issues is grounded in a long-standing historical divide between health in the community setting (focused on prevention of illness) and hospital-based medicine (focused on treatment). the latter particularly privileges the doctor as authority figure. william hsiao (2020, pp. 96-97) , a harvard economist, notes: "there are many statistics that illustrate the flaws of the u.s. health-care system", where "the united states is the only advanced economy that does not offer universal health care coverage". where americans spend nearly twice as much per capita on health care than other advanced post-industrial economies, in comparison with european, japanese, australian and canadian societies, americans have "lower life expectancy, higher infant mortality rates, and a higher prevalence of heart disease, lung disease, and sexually transmitted diseases", where income inequality feeds health disparities grounded in poverty and structural racism. this is fed by a dominant values system that resists conservation and celebrates consumption. hsiao notes that around 30% of the capital spent on health care per annum in america is wasted just as vast amounts of food and energy are wasted. this amounts to $1 trillion a year bleeding out from the health care budget. fraud and abuse in insurance claims, high administrative expenses, and duplication of services all add to this waste, yet, again, many americans still do not have any or adequate health insurance. hsiao (ibid, p. 99) notes: "health care still remains primarily a private-sector activity driven by the profit motive". here, i am reminded of an acid remark of the celebrated socialist economist john maynard keynes (1930) : "the love of money as a possession -as distinguished from the love of money as means to the enjoyment and realities of life will be recognised for what it is, a somewhat disgusting morbidity". daniel e. dawes (2020) meticulously tracks the development of president barack obama's "comprehensive health care reform" initiated in march 2009, as a model for "the political determinants of health". 'obamacare' was an attempt to address the dilemma of health insurance for all. by july 2009, under pressure from opponents of reform, the president referred to "health care reform" dropping the descriptor "comprehensive", and by august 2009, this had mutated to "health insurance reform". dawes shows how political machinations practically wrecked the plan for health care for all, and how, after donald j. trump's election as president in 2016, efforts have been made to sabotage and dismantle the proposal. but dawes does not get at the root reason why universal health care is so disliked in america, where it is perceived as big government meddling in an individual's business. many individuals saw compulsory obamacare as a 'soviet-like' intrusion on choice. as we shall see, this rabid individualism-a key identity position in particular for wider american culture (bellah 2008 )-also permeates american medical education. in the late 1940′s, president harry truman tried to introduce a universal health care insurance, but this was vigorously blocked by the american medical association (ama), which stirred up a bitter campaign to disparage truman's plan, labelling it "socialized medicine" and even calling it "un-american" and supporting "the moscow party line" (hsiao 2020) . during the same postwar period, uk doctors responded in the same reactionary way to initial proposals for a national health service, fearing they would lose private work. this stubbornness against government intrusion is part of a frankly hysterical element in the american psyche that so treasures individualism that it favours citizens carrying guns, despite the consequences for high levels of gun crimes. true to type, stanley goldfarb complains about the american college of physicians making statements supporting gun control, suggesting that here medicine has "stepped out of its lane", or is meddling in politics. there are 40,000 deaths in the usa annually from gun use, and treating injuries from firearms costs $230 billion annually. guns are the leading cause of death among children and adolescents and african american youth, and are implicated in 70% of over 8000 suicides per annum. it was the powerful national rifle association (nra) and the pro-gun lobby who recently advised doctors to "stay in their lane" when issuing statements on gun control and safety. in the usa, while physician political action committees (pacs) are common, doctors seem reluctant to upset the nra and wider gun lobby. this echoes an earlier era where doctors were not outspoken enough about tobacco use as they remained in some cases financially supported by the tobacco industry. but change may be afoot. rebecca cunningham and colleagues (cunningham et al. 2019) report the "beginning of the end of the medical community's silence on the issue of firearm research and safety". goldfarb also notes disapprovingly: "during my term as associate dean of curriculum at the university of pennsylvania's medical school, i was chastised by a faculty member for not including a program on climate change in the course of study", where "such programs are spreading across medical schools nationwide" as if this were an unwelcome infection. indeed, the ama now welcomes such programmes. out-of-touch sceptics such as goldfarb, meanwhile, might take heed of analyses such as that of alice hill and leonardo martinez-diaz (2020, p. 107) who suggest that "lost productivity due to climate-related illness are projected to consume an estimated $500 billion per year by the time a child born today has settled into retirement". goldfarb chastises medical schools for "inculcating social policy" when they should be teaching students to "cure patients", and blames "a new wave of educational specialists" who are "increasingly influencing medical education", to emphasise "social justice" topics "at the expense of rigorous training in medical science". this in turn, claims goldfarb (and here is the rub), comes of a mindset that "abhors hierarchy of any kind and the social elitism associated with the medical profession in particular". further, "the prospect of this 'new,' politicised medical education should worry all americans". then goldfarb lays the blame at the doorstep of socio-cultural learning theorists supposedly infecting medical education: "theories of learning with virtually no experimental basis for their impact on society and professions now prevail. students are taught in the tradition of educational theorist étienne wenger, who emphasized 'communal learning' rather than individual mastery of crucial information". what is wrong with "communal learning"? surely this is in any case unavoidable, where no person is an island. indeed, contemporary psychology points to 'self' as a delusion and a philosophical category error, in a networked world in which both skin-to-skin social connections and technology enhanced virtual connections are the norm (oliver 2020). well before our virtual age, i know of no better description of collaboration than the celebrated passage in herman melville's moby dick, where ishmael and queequeg are roped together for efficiency as they attend to a whale's carcass, dangling over the edge of the ship. if one goes, then the other goes too. melville describes this "as the precise situation of every mortal that breathes". goldfarb and others' collective prejudice for individualism in any case runs counter to the evidence base for the effectiveness of collectivism advertised by inter-professional clinical teams. for example, changes in operating theatre practices that embrace the mandatory global surgical safety checklist must include collaborative briefing and debriefing of lists, found to improve surgical outcomes (gawande 2009; haynes et al 2009) . further, more democratic team structures in healthcare lead to better patient outcomes, also improving patient safety and worker satisfaction (borrill & west 2002) . the source of prejudice against collectivism may rest with a values system grounded in an unexamined emphasis upon the moral status of the heroic individual, the heart of protestant-capitalist ideology (as argued by max weber (2002) in the protestant ethic and the spirit of capitalism, first published in german in 1905 and not translated into english until 1930). subscription to such a values perspective leads to a prejudice against nationalised and centralised healthcare, and collaborative rather than individualistic practices of learning. democracy is translated back to the freedom of the individual (such as the right to bear arms) rather than progressed forward to collective responsibility, however tough to achieve as compromise is always built in (participatory and democratic clinical team process). goldfarb's doomsday polemic properly attracted a largely hostile online response. one hundred and fifty plus alumni of the pennsylvania's school of medicine bothered to strongly refute his claims. on medscape (zheng 2019), penn med graduate doctors said: "we are compassionate, socially responsible, and grounded in the deep-rooted belief that doctors are vehicles for social justice. we believe that social justice should not only have a place, but a central place, in the medical school curriculum". what then are the historical conditions of possibility for the emergence of such rabid individualism (expressed as 'selfhelp') and demonizing of collectivity? traditions of self-sufficiency permeate mainstream medical education. self-help's centre of gravity for over a century has been north america, but its birthplace is scotland. the scottish doctor, author and reformer samuel smiles , who trained in medicine at edinburgh, published self-help in 1859. smiles was critical of excessive wealth and materialism, but he also thought that poverty was a product of irresponsibility, and avoidable. ironically smiles, one of eleven children, was supported through medical school by finances provided by his mother, after his father had died from cholera. in the 1840′s, smiles engaged deeply with political reform, arguing for democratic principles including the rights of women. but by the 1850′s, he had stopped campaigning for general political reform as he vigorously promoted the idea of self-sufficiency. self-help sold 20,000 copies in the first year of publication, and by the time of smiles' death in 1904 the book had sold over 250,000 copies. orison swett marden , an american physician and polymath, had degrees in law, science, and arts as well as medicine. orphaned at the age of seven, as a teenager marden fortuitously came across a copy of self-help and was smitten with smiles' ideas. marden wrote his own self-help book pushing to the front. published in 1894, it was the first and most influential popular psychology book in america. by 1925 it had run to 250 editions and became a global bestseller. spurred on by the initial success of his book, in 1897 marden founded a magazine called 'success', with a circulation of 500,000. it was indeed a runaway success as the first motivational self-help journal. by then, marden had left medicine, turning his back on hospitals to enter the hospitality industry. he ran several hotels and a holiday resort, and eventually employed over 200 people to produce and deliver his periodical. in 1916, he became the first president of 'the league for the larger life' in new york, an organisation whose mission statement was "to spread a knowledge of the fundamental principles that underlie healthy and harmonious living" and "to assist the individual in the solution of personal problems". the 'pop' psychology, personal development culture was established, grounded in the wider values of the 'lone frontiersman' mentality of heroic-individualism, self-sufficiency, strong work ethic (protestantism's main secular value) and opportunistic capitalism. here, private feelings and emotional life become commodities for capitalist enterprises of self-help an therapy, as arlie russell hochschild (1983) in particular details in the managed heart: commercialization of human feeling. the uk's observer newspaper recently reported a boom in sales of self-help books, particularly pertaining to mindfulness, with sales of 3 million in 2019 (walker 2019). in france, nearly 15 million self-help or health and wellbeing improvement books were sold in 2018, compared with 10 million cookery books and 3 million books on gardening, animals and nature (staista 2019) . the self-help or personal growth market in the usa is now turning to 'life coaching' and is worth $10 billion, predicted to rise to $12 billion by 2022 (larosa 2018). while more women than men read self-help books, more men than women write them (zhou 2017) . stressing the 'frontiersman' virtues of resilience and persistence (core to self sufficiency) and the protestant work ethic, orison marden recounted how his first manuscript copy of pushing to the front had been destroyed in a fire when one of his hotels burned down. he immediately wrote three new versions and sent them simultaneously to three different publishers each wanted to publish the book. again, marden, inspired by samuel smiles, had created the self-realisation movement that today we know by descriptors such as 'personal growth' and 'humanistic psychology', and that has exploded through you tube and social media, affording a significant psychological public health intervention. marden himself was almost certainly influenced by a 19th century american movement called 'new thought' formed initially by the ideas of phineas quimby. drawing on ideas from a number of religious denominations, the new thought movement's doctrine was that health is a product of 'right thinking', and conversely, sickness a product of 'wrong thinking'. in short, the individual is in charge of his or her fate, and responsible for his or her actions, where psyche precedes and shapes soma. the scottish-american industrialist and philanthropist andrew carnegie (1835-1919) made a fortune from producing steel. he was a staunch believer in independence, the protestant work ethic and self-help, and admired marden's work in particular. carnegie set up a charitable foundation to re-distribute around 90% of his considerable fortune (around $65-70 billion in today's money). there was, however, a dark side to carnegie's beliefs that also characterised samuel smiles' philosophy: those who could not help themselves were seen as either weak or lazy and should be allowed to perish. this twisted reading of darwinian 'survival of the fittest' offered a cruel injunction to the physically or mentally challenged, or to those stuck in a poverty trap. marden's and carnegie's shared value system would come to describe a cultural style and trait among north americans that would shape educational systems and pedagogical practices, focused on self 'improvement'. its main proponent would be john dewey, born in the year that samuel smiles' self-help was first published (1859) and a contemporary of both marden and carnegie. dewey was a firm believer in democracy, but more, in autonomy. democracy advertised individual freedom of expression rather than compromise for the common good. this has now become the credo for neoliberal (free-market and competitive) capitalism, and has proved to be illusory. 'self help' readily becomes 'every man for himself'. should ishmael or queequeg encounter trouble, one would cut the tie and clamber to safety, leaving the other to plunge onto the carcass of the whale into a mess of trouble. the darker competitive side of samuel smiles' legacy has dominated north american pedagogy and this has bled into medical education, including western european versions. the individual, and the cult of individualism expressed competitively (prizes! awards! leadership! mastery!), has been a primary driver for medical pedagogies. (this is not to ignore the major influence of liberatory and explicitly politicised and activist educationalists such as paulo freire). where success stems from self-reliance, so failure is described as reliance on others. recall stanley goldfarb's invective recounted earlier, where in medical education: "theories of learning with virtually no experimental basis for their impact on society and professions now prevail. students are taught 'communal learning' rather than individual mastery of crucial information". such 'mastery' carries the sinister overtones of a master/slave relationship refusing reciprocity and productive social bonds. the self-help philosophy of marden, the pedagogy of dewey, and the philanthropy of carnegie converge in the work of abraham flexner, an ambitious educationalist who ran his own innovative school. for the origins of modern medical pedagogy, we must go back over a century to the politics of abraham flexner and his hugely influential reports on medical education in north america and canada (flexner 1910) ; and, two years later, in europe. these have been picked over many times by contemporary medical educators. importantly, brett schrewe (2013) argues that flexner has now become mythologised through a "metanarrative" that surely clouds rather than illuminates our understanding of his contribution to hpe. the flexerian myth suggests that the shape of modern medical education should be ascribed to the work of one man again, an heroic endeavour. a classics graduate turned educationalist, abraham flexner was a contemporary of orison marden, his educational inspiration was john dewey, and the funding that allowed his vision of medical education to be realised was gained originally from the legacy of andrew carnegie in the form of the carnegie foundation for the advancement of teaching. this was not explicitly a cabal, but the interconnections between the members of this male group are surely as interesting as the individual figures. flexner's (1910) medical education in the united states and canada: a report to the carnegie foundation for the advancement of teaching is in fact a text of immense political and ethical interest. the carnegie foundation did not want a doctor to carry out the on-the-ground research and subsequent writing of the report, but somebody who would be dispassionate about medical education. many considered flexner (1866 flexner ( -1959 to be the most important educationalist of his era, even more so than his contemporary john dewey (1859-1952) whose educational methods flexner greatly admired. on his death, the new york times front page obituary said of flexner: "no other american of his time contributed more to the welfare of his country and of humanity in general". not everybody agreed. an american doctor, lester king (1984) called flexner's report "probably the most grossly overrated document in american medical history", pointing out that recent medical historical scholarship has placed flexner among a network of many equally important figures and factors influencing medical education of his time. the celebrated medical historian kenneth ludmerer (1999) agrees, as we shall see. flexner was the sixth of nine children born to german jewish immigrant parents in louisville, kentucky. his father moritz was a hat seller and his mother esther a seamstress. his eldest brother jacob supported flexner through his first degree at johns hopkins university in baltimore. flexner completed his bachelor degree in 2 years. jacob, a pharmacist, later trained as a doctor, while flexner's older brother simon became a renowned pathologist and bacteriologist. flexner taught greek and latin at high school, and on the back of private education tuition from wealthy donors set up his own experimental school in which lessons were not compulsory and students did not enter for exams. yet many went on to attend prestigious universities and colleges, and the school gained a reputation for educational innovation. flexner married one of his former students, anne crawford, who had become a teacher and playwright. she had a broadway success and the profits financed flexner to close his school and study full time for a master's degree in psychology from harvard, and then to spend a yearlong sabbatical in germany at berlin and heidelberg universities, something of a homecoming, where he decided that the german educational system was the finest in the world. the wealthy carnegie foundation asked flexner in 1908 to conduct the planned survey of the quality of medical education in north america and canada. the president, henry s. pritchett, had read flexner's recently published (1908) critique of higher education, the american college: a criticism, in which flexner attacked in particular large lecture teaching as a 'cheap' and 'wholesale' way of turning education into cruder management of learning. flexner was taken by surprise at the invitation as he knew nothing about medical education and had never set foot inside a medical school. when he did, what he saw shocked him. from january 1909 to april 1910, flexner visited all 155 medical schools in north america and canada, some only briefly but some of them twice, clocking up 175 visits. most visits revealed available medical education to be largely a totally unacceptable way to prepare doctors for practice. within the dominant flexner narrative, in the majority of schools, admissions policies were poor, haphazard or non-existent. curricula had no formal shape. pedagogies went unexamined. resources were lacking 140 of the 155 schools had no library; schools were poorly equipped and had no link with nearby hospitals. yet the certificates received upon completion of studies licensed graduates to practice medicine. most importantly, there was an over-production of doctors (flexner claimed four to five times as many doctors were being trained in north america as in germany per head of population). only one school-johns hopkins in baltimore, flexner's alma mater-required entrants to possess a prior degree. flexner took this institution as his standard for future development of medical schools. he did not think along lines of equity and equality, such as how such poorly performing schools could be better resourced or helped a 'seeding' approach. rather, he set a standard and then employed the scythe, and brutally. as fee-paying private institutions, medical schools were more interested in profits than standards, often recruiting their students from industrial occupations. flexner had apparently uncovered a scandal. fifteen thousand copies of his report were printed and distributed free of charge causing widespread alarm. by 1922, of the 155 schools only 81 remained. flexner himself had called for a maximum of 31. he initiated four major changes: medical schools would be university based; faculty would be involved in research, both scientific and educational; students would be recruited only after obtaining an undergraduate degree in sciences; and would learn through a standardised curriculum of two years of anatomy (through cadaver dissection) and bench sciences, followed by two years of clinical study through the university's attachment to hospital settings. in a comprehensive history of north american medical education kenneth ludmerer (1999) points out that flexner's extreme foregrounding from a background of multiple medical educational activities provides a distorted picture. flexner did not suddenly initiate modern medical education singlehandedly, while his observations of medical schools often suffered from a lack of appreciation of how far many schools had come since inauguration especially those that catered for women and minority groups. appalled by the laxity of home-based medical education, some more thoughtful, inquisitive and morally sensitive -american doctors had gained experience in germany where medical students underwent a rigorous education, first socialised as anatomists (through cadaver dissection) and then bench scientists before engaging in clinical medicine. ludmerer (ibid, p. xxii) shows that the flexnerian revolution had antecedents since the mid-nineteenth century "when a revolution occurred regarding how medicine should be taught". the revolution was not confined to medicine, but was one of ideas and adventures in pedagogy based on a social contract. capitalist society, driven by entrepreneurs, would provide the climate for the generation of schools and universities, including medical schools. in turn, doctors educated in these schools would engage in a social contract in which they committed not only to serving communities, but also to developing the highest possible standards of research and professionalism within their field. as ludmerer (ibid.) says, this was a "financial, political, and moral" exchange. financial capital flowed in to medical school development not in dribs and drabs, but in huge quantities, reflecting flexner's new influential role at the carnegie foundation and then the rockefeller foundation. ludmerer (ibid, p. xxiii) notes that in 1910 a leading medical school may have a budget of around $100,000, by 1940 that would have swelled tenfold, to $1 million. more sinister is whether or not flexner had consciously decided to come down heavily on those schools that catered for women and minorities (hodges 2005) . they were the most vulnerable, short of funding and then equipment and expertise. nowadays, as noted above, we would see this as good reason to support them and invest in them to counter both inequity and inequality. it did not seem to matter to flexner that women would be dispossessed of the opportunity to study medicine -a condition that persisted until relatively recently. however, there were certainly open motives for discouraging people of colour to study medicine. flexner suggested that black doctors should only work with black patients using the spurious argument that such doctors might infect white patients with illnesses carried only by people of colour (nevins 2010 ). flexner's view about race issues was complex. in a letter from 1930 concerning recruitment of staff at princeton university, flexner's belief in offering opportunities to all individuals is clear: "it is fundamental in our purpose, and our express desire, that in the appointments to the staff and faculty as well as in the admission of workers and students, no account shall be taken, directly or indirectly, of race, religion, or sex". further, while flexner was jewish, he never openly spoke out against anti-semitism and was strangely quiet when hitler came to power. in the 1930s, when high-profile jewish intellectuals and scientists emigrated to america, flexner was often involved in employing them through his role as founding director of the institute for advanced study at princeton, where his biggest 'catch' was albert einstein. as michael nevins (ibid.) argues, flexner's achievements in pedagogy and medical education have been lauded, while his infamous character flaws of irascibility and narcissism have been noted, yet his values and beliefs, despite his 1940 autobiography and an update in 1960, remain opaque or cloudy, complex, contradictory and difficult to decipher. he must have been conflicted over his love for the german educational system, his jewish ancestry, and what he was seeing in germany as hitler came to power, but he never made this plain. nevins asks why flexner did not openly come out against institutionalized anti-semitism that was reflected in the popularity of the eugenics movement in america during the first half of the 20th century. the german sociologist max weber (1864 -1920 was a contemporary of marden, carnegie, dewey and flexner. first published in 1905, but not translated into english until 1930, and then probably unknown to the spearhead figures in american self-help and self-sufficiency thinking, weber put forward a radical idea in the protestant ethic and the spirit of capitalism. goethe's 1809 novel elective affinities took the idea-prevalent at the time-that certain chemicals were attracted to other chemicals and would react with these and not with others. goethe took this as a metaphor for human passions and relationships. we still use the term 'chemistry' to describe such affinities. weber poached goethe's idea to explore social and intellectual bonds. he was puzzled as to why market-driven capitalism was so successful in the western world, and suggested that this can be explained by capitalism's elective affinity with the central ethic of protestant belief: 'getting ahead' through self-help and independence, or what we now call a 'work ethic'. protestant calvinism in particular, popular in scotland, england, germany and the netherlands, mapped on to the rapid development of capitalist economies in these european countries when compared to catholic-dominated countries such as spain, france and italy. calvinism encouraged hard work in this life with reinvestment of profits (rather than what was seen as frivolous spending) to set up salvation in an afterlife. more, buying in to this predestination eased any conscience about social and economic inequality in this life -that could be put down to others' laziness or indulgence. we have seen that flexner's fieldwork inquiry and subsequent report uncovered a common model amongst north american and canadian medical schools. whatever their quality and standing, they were all profit-seeking private institutions or businesses. paradoxically, drawing more on john dewey's idea of independent learning than on democratic engagement as the primary pedagogy for medical education, flexner's purging and reconceptualising of medical education drove curricula deeper into capitalist ideology, where knowledge and skills were obtained through individual effort and retained as personal capital. with flexner's initiative, the political body of north american (and then western european) medical education is laid bare. in short, the dominant model of learning remained individualistic and not social, as free-market neoliberal capitalistic and competitive, certainly up to the dawn of the twenty-first century. collaborative or socio-cultural learning theories were still on the horizon. marxist dialectical materialism, where physical objects and artefacts (including languages and symbol systems) played an equal role in learning along with the humans who drew on them, was until recently for most medical educators a foreign language. medical educators whose pedagogies celebrated individual achievement ignored the work of american scholars who had spent time in russia studying collectivist and dialectical-materialist learning theory, such as the psychologist michael cole (cole et al. 1997 ). so, for example, peer assessment methods were never properly explored, while the collectivity possible in problem-based learning was consistently displaced by focus on individuals' efforts and how these could be isolated and assessed. stanley goldfarb, above, speaking for an entrenched conservative view, complained of both political activism and pedagogical collectivism tainting contemporary medical education, where "the prospect of this 'new,' politicized medical education should worry all americans". as noted earlier, he lays the blame at the feet of social (and socialist) learning theorists: "students are taught in the tradition of educational theorist étienne wenger, who emphasized 'communal learning' rather than individual mastery of crucial information". poor étienne wenger, who came from a medical family but decided to study psychology, and never wrote a thing about medical education until late in his career. wenger's work, with his colleague the anthropologist jean lave, was focused on craft apprenticeships in areas such as the work of butchers. better that he target the psychologist michael cole, mentioned above, who on the advice of jerome bruner went to study learning theory in moscow in 1962 for a year, under the direction of alexandr luria. or yrjö engeström, the leading finnish educator, who has done more than anybody globally to promote and develop cultural-historical activity theory (chat) (a descriptor coined by cole) first developed by the russian psychologist lev vygotsky after the 1917 revolution. engeström too has worked in america on and off since the 1980′s, at the university of california, san diego in a department founded by cole, where engeström (1999) says: "i had to learn about multiculturalism and to appreciate ethnic, religious, and other differences between people". here then is a glaring paradox -engeström, seeped in collectivist tradition in helsinki, learns about multiculturalism in san diego, but north american hpe fails largely to learn from collectivist chat. social learning theories did not register in the medical education literature until the early 2000s (bleakley 2006) . michael cole later became a translator and editor of luria's writings and, for over three decades, was editor of the journal soviet psychology. cole's political interests came partly from the influence of his father, lester cole, a hollywood film screenwriter who held leftwing views and was under surveillance during the height of the mccarthy era. he refused to answer questions when interviewed about his possible communist affiliations, along with a group of hollywood directors and writers who became known as the 'hollywood ten'. in conclusion, stanley goldfarb and others should know better -all medical students and junior doctors learn in social or communal settings such as inter-professional teams on ward rounds, crash teams in resuscitation scenarios, or surgical teams in the operating theatre, and the evidence base shows -as noted earlier-that the more collaborative the team, the better the outcomes not only for patients' health and safety, but also for team members' work satisfaction. goldfarb and others, i guess, would not welcome medical students and junior doctors challenging the system to afford innovation, but would wish neat and quiet absorption into traditions of individualism without a hint of revolution. you would think that current generations of medical students and junior doctors would surely change that, after #metoo and black lives matter, but lingering traditions of heroic individualism are so entrenched that they will surely persist (sabin 2012) . such entrenchment would mirror what yrjö engeström (2018) calls a "will-to-stability", as opposed to the horizon of "possibility knowledge" achieved through questioning unproductive historical habits. social learning theories follow a model of dialectical learning, in which challenge from below is invited and contradiction is the engine of change. medicine's major contradiction is that, within multi-professional healthcare provision, it remains a stubbornly hierarchical culture while advertising patient-centredness and interprofessionalism, or "co-ordinated care". medicine must democratise, and quickly. john dewey's dilemma was how to fuse rabid autonomy and unbridled capitalism (the american way) with democracy, to give equal weight to 'mind' and 'culture'. how should the individual mind and "habits of the heart" adapt in commitment to collaborative democratic progress? dewey's answer was to integrate culture into individual mind, as a commitment to collective endeavour without losing individual rights and freedoms. this is the american way (sabin 2012) . but this path morphed into what kenneth galbraith (1992) derides as a "culture of contentment", one of smug self-satisfaction in the face of growing structural inequities and inequalities. rather, as michael cole insisted, we should integrate mind into culture, as extended cognition and affect. in this 'ecological perception' view, the 'mind', or thinking and feeling, is not in the skull, but is afforded by interactions between environmental context and human intentions. context includes artefacts such as technologies, languages and semiotics (signs and symbols). human intentions include 'predictive processing'-the ability to link improvised activity with changing environmental cues (clark 2015) . if we take this model of cognition seriously, then 'individualism' is already a mis-description, as we are all embedded (and then embodied) in a wider ecological context of shared technologies and languages. in the neoliberal capitalist model, as individuals gain more money, power and prestige, they typically abandon collectivism and drift away from the common good. the less successful are cast adrift, because now we know that as the economic tide rises, it does not bring all boats with it (piketty 2014) . the socialist way in contrast is to sacrifice individualism for what the collective can afford the individual. this honours principles of equity and equality. while equality provides the same measures for all, equity provides differing measures depending on needs. following alexandr luria's maxim that "the determining factor in the psychological development of the child is the social development of the child", if goldfarb had, for example, been born in cuba, or even a scandinavian country where individualism is subsumed in the collective ideal, he probably would have followed a quite different set of values as a doctor and medical educator. i have -often polemically -argued for the value of a collectivist hpe over an individualistic model and have provided a rationale for this. ahse is a journal that has been at the cutting edge of thinking and practice in the arena of hpe, recognising that major advances in healthcare have been achieved through genuine patient-centred and inter-professional collective care team practices. again, i applaud geoff norman's pivotal role in advancing work in the field. habits of the heart: individualism and commitment in american life broadening conceptions of learning in medical education: the message from teamworking patient-centred medicine in transition: the heart of the matter team working and effectiveness in health care: findings from the health care team effectiveness project surfing uncertainty: prediction, action, and the embodied mind mind, culture and activity money, politics, and firearm safety: physician political action committees in the era of the political determinants of health learning by expanding: 10 years after expertise in transition: expansive learning in medical work medical education in the united states and canada: a report to the carnegie foundation for the advancement of teaching the culture of contentment the checklst manifesto: how to get things right take two aspirin and call me by my pronouns a surgical safety checklist to reduce morbidity and mortality in a global population adapt or perish: preparing for the inescapable effects of climate change the managed heart: commercialization of human feeling the many and conflicting histories of medical education in canada and the usa: an introduction to the paradigm wars it's the biggest science policy failure in a generation how to fix american health care: what other countries can-and can't-teach the united states economic possibilities for our grandchildren xx the flexner report of 1910 development of the concept of patient-centredness -a systematic review the $10 billion self-improvement market adjusts to a new generation time to heal: american medical education from the turn of the century to the era of managed care abraham flexner: a flawed american icon the self delusion: the surprising science of how we are connected and why that matters capital in the twenty-first century medicine and society from history to myth: productive engagement with the flexnerian metanarrative in medical education stressed brits buy record number of self-help books observer sat the protestant ethic and the "spirit" of capitalism and other writings an open letter to our former dean, dr stanley goldfarb, from 150+ alumni of the university of pennsylvania school of medicine goodreads data show that women reading self-help books are getting advice from men. quartz key: cord-026742-us7llnva authors: gonçalves, judite; martins, pedro s. title: effects of self-employment on hospitalizations: instrumental variables analysis of social security data date: 2020-06-15 journal: small bus econ doi: 10.1007/s11187-020-00360-w sha: doc_id: 26742 cord_uid: us7llnva the importance of self-employment and small businesses raises questions about their health effects and public policy implications, which can only be addressed with suitable data. we explore the relationship between self-employment and health by drawing on comprehensive longitudinal administrative data to explore variation in individual work status and by applying novel instrumental variables. we focus on an objective outcome—hospital admissions—that is not subject to recall or other biases that may affect previous studies. our main findings, based on a sample of about 6,500 individuals followed monthly from 2005 to 2011 and who switch between self-employment and wage work along that period, suggest that self-employment has a positive effect on health as it reduces the likelihood of hospital admission by at least half. the self-employed represent nearly 16% of employment in the european union (eurostat 2017) . moreover, as much as 10% of the adult population of the eu has used online platforms for the provision of labor services at some point in their lives (pesole et al. 2018) . the ongoing growth of the "platform" economy contributes to the expansion of the proportion of self-employed, especially among younger workers, and raises a number of public policy questions regarding, for example, occupational health and safety risks, social protection, and representation (european commission 2017; garben 2017; ilo 2016) . indeed, platform economy jobs-and self-employment more generally as well as some types of small businessesare characterized by more flexible work formats, distinct from formal employer-employee relationships framed by employment law, and typically have more limited access to social protection. 1 in the current context of such novel forms of selfemployment, one important issue concerns the impact of self-employment on workers' health-the subject of this study. occupational characteristics, namely job control and job demand, vary significantly between self-employment and wage work. job control stands for decision authority, e.g., the freedom to decide what work to do, when and at what pace, which reduces work-related stress. job demand, on the other hand, represents sources of stress at work, such as being assigned a considerable amount of work and/or having little time to carry out specific tasks. this job demand-job control framework, proposed by karasek (1979) , karasek and theorell (1990) , and theorell and karasek (1996) , suggests that compared with wage work, self-employment is associated with both higher job control and higher job demand, an interaction termed 'job strain' in the literature (prottas and thompson 2006; stephan and roesler 2010). 2 in fact, self-employed individuals are not subject to orders from other workers higher up the organizational hierarchy, so they have more decision authority and potentially lower work-related stress. research also shows that the self-employed are more satisfied with their jobs than wage workers because they can be creative and have more autonomy. in other words, the self-employed may often be able to derive utility from the way outcomes are achieved, a process sometimes referred to as 'procedural utility' (benz and frey 2008; schneck 2014) . however, when self-employed, labor income and assets directly hinge on one's ability to work and work effort in each period. in addition, greater exposure to unanticipated demand shocks leaves selfemployed individuals subject to more volatile workload and income flows. social support at work may 1 note that the covid-19 crisis and its aftermath may contribute to the growth of self-employment, as wage employment opportunities in the labor market will decrease. additionally, the covid-19 crisis may lead to a larger share of wage employment conducted under remote work formats given their social/physical distancing properties. such remote work formats are typically more common among the self-employed, which may lead to some blurring of the differentiation between wage work and self-employment. 2 see, e.g., ingre (2017) for a discussion of the job strain model with respect to the appropriateness of the interaction between the job demand and job control dimensions in karasek's model. also be more limited given the smaller number of co-workers around (blanch (2016) , discusses the demand-control-support model). all these variables represent sources of stress. given these two opposite mechanisms-higher job demand and higher job control-it is unclear whether we should expect selfemployed individuals to suffer from more or less work-related stress, compared with wage workers. the medical literature identifies stress as an important cause of disease, e.g., cardiovascular problems and digestive disorders (mayer 2000; steptoe and kivimäki 2012) . overall, stress impacts negatively on health and well-being, and in addition to increasing incidence of disease, it may increase absence from work due to sickness and use of health care services (e.g., browning and heinesen 2012; halpern 2005; holmgren et al. 2009 ). bloemen et al. (2018) also find that the probable mechanism driving the effect of job loss on mortality is stress, through acute diseases of the circulatory system. stress is also associated with unhealthy behavior, such as smoking and drinking. the typical occupations of self-employed and wage workers may differ in terms of risk of workplace accidents and other occupational hazards. at the same time, in many countries self-employment is subject to little or no social protection, in terms of coverage by occupational safety regulation, social security, employment law, or collective bargaining, potentially representing additional negative implications for health. on the other hand, the greater flexibility regarding regulation may also represent additional work opportunities compared with wage work. overall, whether self-employment has a positive or detrimental effect on health is a public policy question that can only be answered with empirical evidence of a causal nature. there are two main empirical challenges to the identification of a causal effect of self-employment on health: reverse causality and individual unobserved heterogeneity (torrès and thurik 2019) . reverse causality has to do with the possibility that individuals become self-employed or wage workers at least partly for health-related reasons. on the one hand, self-employment may attract individuals that are healthier on average because healthier individuals tend to be more able to focus on business opportunities or may have easier access to financing (e.g., gielnik et al. 2012 ). additionally, income when self-employed tends to be more closely linked to one's ability to work than when a wage worker, and access to sickness benefits is harder for the self-employed. all these factors suggest a positive (self-)selection of the healthy into self-employment. on the other hand, health problems may constitute a barrier to finding a wage job, particularly if they are visible to the employer, and push individuals who are less healthy into self-employment (e.g., zissimopoulos and karoly 2007) . furthermore, several individual traits that are difficult to measure may be related to both health and selfemployment decisions (bujacz et al. 2019) . examples include optimism, perseverance, resilience, risk aversion, as well as genetics. some individuals who are attracted to and persist in self-employment may also have higher capacity to tolerate and manage stress, and may therefore experience lower stress (baron et al. 2016) . this capacity to deal with stressful factors is another example of an individual characteristic related to both health and type of employment. earlier life circumstances such as childhood health also influence adult health and type of employment (case et al. 2005; case and paxson 2010) . taken together, these traits and earlier circumstances mean that self-employed individuals and wage workers may have different health profiles along dimensions not observable in the data. the empirical literature on self-employment and health is growing but still scarce. most of it is plagued by the endogeneity issues mentioned above, which are difficult to tackle without longitudinal data. a recent study finds significantly lower work-related stress among self-employed individuals without employees compared with wage workers, using longitudinal data from australia and controlling for individual fixed effects (hessels et al. 2017) . previous studies on selfemployment and stress provide contradictory findings, but most of them are based on cross-sectional data and use descriptive methods (see hessels et al. (2017) , table 1 , for a review). in the study by rietveld et al. (2015) , selfemployed individuals appear healthier than wage workers. however, while the positive association between self-employment and health holds when the authors control for reverse causality, it vanishes when they control for individual unobserved heterogeneity. this finding suggests a positive selection of the healthy into self-employment. that study considers subjective health measures, including self-reported number of conditions, overall health, and mental health. it uses longitudinal survey data representative of the population 50+ in the usa. the results may therefore not be generalizable to a broader workingage population. another study by yoon and bernell (2013) relies on cross-sectional survey data representative of the adult population in the usa and adopts an instrumental variable approach. the authors find that selfemployment has a positive impact on several health indicators, namely the absence of chronic conditions such as hypertension and diabetes. they find no effects on other health outcomes, including perceived physical health and mental health. nikolova (2018) , using german longitudinal survey data and a difference-in-differences strategy, finds that switching from wage work to self-employment leads to both physical and mental health gains. considering more objective indicators and administrative data, a five-year follow-up study of the total working population in sweden finds that selfemployed individuals who own limited liability companies (but not sole proprietors) have lower average risk of mortality than wage workers (toivanen et al. 2016) . similarly, toivanen et al. (2018) find that limited liability company owners have lower rates of hospitalization for myocardial infarction than wage workers, and no different hospitalization rates for stroke. the authors unveil relevant heterogeneous effects not only by enterprise legal type of self-employed individuals but also by industry. overall, there is little robust evidence on the causal effect of self-employment on health. most of the literature does not take endogeneity into account, as longitudinal data or instrumental variables are seldom available. furthermore, it is important to distinguish the effect that is due to differences in the intrinsic characteristics of self-employment and wage work, namely job control and job demand, from institutional factors such as different access to social security benefits. this may be difficult with survey data and selfreported health indicators. separating-out the effect that is due to differences in the typical occupations of self-employed and wage workers, which are associated with different exposure to occupational hazards, would also be of interest. the main research question in this study is "what is the impact of self-employment on the likelihood of hospital admission?" we answer this question based on a large sample of administrative social security records representative of the working-age population in portugal, that includes almost 130,000 self-employed and wage workers followed between january 2005 and december 2011. we focus on a subsample of about 6,500 individuals who switch between self-employment and wage work along that 84-month period. we contribute to the literature in several ways. first, we tackle explicitly the endogeneity of the decision to become self-employed by controlling for individual fixed effects and employing instrumental variables. second, looking at hospitalizations allows us to separate-out institutional factors, because access to hospital care and social security benefits when hospitalized are unrelated with type of employment, and most hospitalizations correspond to unplanned or unavoidable acute events. administrative records of hospital admissions are also comparable across individuals and time periods and not subject to recall bias, an advantage over self-reported indicators in survey data. third, to explore to which extent the effect may be due to differences in the typical occupations of self-employed and wage workers, we look at diagnoses underlying hospitalizations. fourth, we consider the whole working population regardless of age, and explore potentially heterogeneous effects across demographic subgroups. lastly, we also investigate the effects of self-employment on the length of hospitalization and mortality. hospital admissions are also a relevant outcome for policy. they represent roughly 40% of health expenditure in portugal. 3 a significant 7% of sickness leave episodes correspond to hospital admissions (own calculations for the years 2005-2011). in 2011, sickness leave episodes cost social security 454 million euros; 4 7% of that represents almost 32 million euros. this adds to the costs for the health system and other societal costs more difficult to quantify, including productivity and well-being losses. the remaining of this paper is as follows: the next section lays down the background for the study, section 3 presents our data and empirical strategy, section 4 presents the results, and in section 5 we discuss our findings. in 2016, about 17% of employment in portugal corresponded to self-employment or own-account workers. more than one-fourth of those had employees. the proportion of own-account workers differs across groups. it is lower in the capital region than in other regions, among women, among younger age groups, and among more educated groups. by industry, we find the largest proportions of own-account workers in agriculture and other primary sector activities (71.5%), real estate (36%), consulting, scientific, and technical activities (29.5%), construction (27.4%), retail (21.3%), hospitality services (20.3%), and artistic and sports activities (19.6%). from the "self-employment" module of the labor force survey (lfs), conducted in the second quarter of 2017, we also know that more than 60% of own-account workers decide their work schedule. they also report much higher autonomy over their tasks than wage workers. this is in line with the hypothesis of higher job control. while only less than 20% of own-account workers report no difficulties with their work over the previous 12 months, 16% report periods without work, and 14% claim that clients do not pay or pay late. this may suggest that the self-employed are subject to higher job demand. own-account workers report lower levels of satisfaction at work than wage workers, although this is driven by the low satisfaction levels of those who have employees. virtually no ownaccount workers report that they would prefer to be wage workers (torres and raposo 2018) . in this study, we adopt the portuguese social security definition of self-employment or "independent workers" (trabalhadores independentes), which does not include own-account workers with employees. family and informal workers, which are captured in the lfs, do not appear in our data, as they do not pay social security contributions. this explains the lower proportion of self-employment in our data, described below, compared with the proportion of own-account workers in the lfs. for example, agriculture and other primary sector activities, which have by far the largest proportion of own-account workers in the lfs, will have limited expression in our data for those reasons. in portugal, statutory sick leave covers both the self-employed and wage workers. as in many european countries, to deter moral hazard, wage workers face a three-day gap from the onset of a sickness episode until a sickness benefit starts to be paid (i.e., waiting or "elimination" period). however, for the self-employed, this waiting period is much longer, at thirty days (ten days from 2018 onwards). due to the different waiting periods, social security records include sickness episodes that last four days or more in the case of wage workers, but at least thirtyone days in the case of the self-employed. the first three/thirty days are not eligible for sickness benefits. thus, all other things equal, the sickness spells of the self-employed that are administratively recorded are, on average, much more selected and severe. these different waiting periods can entail different incentives for wage workers and self-employed individuals. wage workers face much lower opportunity costs from reporting sick to work, i.e., fewer days without income. in some cases, collective bargaining provisions, determined by unions and firms or employer associations, may even lead to the payment (by the firms) of the first three days of absence as well. as these provisions apply to wage workers but not to the self-employed, the former may engage more often in moral hazard: "cheat" by going on sick leave when they are not really sick. in stark contrast, there is no waiting period for either self-employed or wage workers in the case of hospitalization. furthermore, benefits are the same for both types of workers. besides, due to the specific, acute nature of hospitalizations, these are less likely to be timed deliberately by individuals and therefore less likely to be artificial episodes of sickness. in sum, compared with standard-i.e., non-hospitalizationsickness episodes, hospitalizations are a significantly more objective outcome and hospital admissions should be strictly comparable between wage workers and self-employed individuals. as to the amount of the support, for nearly the entire period under analysis here (sep 2005-dec 2011), the replacement rate of the portuguese sickness benefit was equal to 65% of forgone wages for the first 90 days of sick leave, 70% from the 91st to the 365th day, and 75% from the 365th day onwards. during the first eight months of 2005, the replacement rate was 55% of forgone wages for the first 30 days of sick leave, and 60% from the 31st to the 90th day. sickness benefits are granted for a maximum of 1095 days for wage workers and 365 days for self-employed individuals (law-decrees 28/2004 (law-decrees 28/ , 133/2012 (law-decrees 28/ and 146/2005 . the portuguese national health service, financed through taxes, provides general and universal coverage and is almost free at the point of use. in portugal, secondary and tertiary care (both acute and post-acute care) is mainly provided in hospitals. general practitioners act as gatekeepers in access to hospital care in the public sector; otherwise, people can be admitted through the emergency department. private voluntary health insurance may speed up access to elective hospital treatment and ambulatory consultations, but it has very limited expression in portugal (<10%) and is not associated with type of work (i.e., self-employment or wage work). some public and private subsystems provide care to specific groups not relevant for this study (public servants, military, banking sector workers). in general, access to hospital care in portugal should be identical for both self-employed and wage workers. the only concern is that self-employed individuals may delay care in order not to lose business, as their income is closely tied to them actually working. (wage workers could also delay care in order to maintain a good reputation with their employer.) because we are looking at hospitalizations, which are generally acute, untimed events, this concern is limited. nonemergency acute interventions are scheduled by the hospital, and because waiting lists are usually long, it is unlikely that individuals pass on the opportunity to receive the care they need when hospitals schedule them, as it may be a long time before a new opportunity arises. we use data from the portuguese social security information system, made available by the instituto de informática public agency. the dataset is a random sample such that included individuals represent both a) at least 1% of all individuals who pay social security contributions and b) at least 1% of all individuals who receive sickness, maternity, or other benefits from social security, stratified by region and gender. we observe individuals on a monthly basis, from january 2005 to december 2011. we use information on whether they are wage workers or self-employed, as well as whether they receive sickness benefits in a specific month due to hospitalization. the data allow us to distinguish sickness benefits due to hospitalization from sickness benefits due to standard (nonacute) sickness spells, as the two cases are treated differently by social security (see section 2). the dataset also includes information on the individuals' gender, age, nationality, place of residence, and income from work, but not their industry or occupation. we drop individuals below 18 and above 65 years old (mandatory schooling age and statutory retirement age). after deleting also observations with missing information on the key variables, we are left with almost 130,000 individuals, of which about 10,000 are self-employed at some point over the period 2005-2011. in our main analyses, we focus on more than 6,500 individuals who switch at least once between self-employment and wage work over that period (which we refer to as 'switchers'). over the 84-monthlong period, there are more than 300,000 individualmonth observations when considering only switchers (almost 7 million individual-month observations in the full sample). to determine the effect of self-employment on the likelihood of hospitalization, we estimate four different specifications of a linear probability model like the following: 5 the binary dependent variable, hosp i,t , indicates whether individual i is hospitalized in month t or not. the variable of main interest is the one-month lag of the self-employment indicator, self-employed i,t−1 , which takes value one if individual i is self-employed in month t − 1. 6 5 we opt for the linear probability model given the computational difficulties associated with applying instrumental variables methods to nonlinear panel data models, especially when various large vectors of fixed effects are included. to investigate if the chosen functional form is appropriate, we estimated the logit/panel logit versions of models 1 and 2 (i.e., with or without individual fixed effects), which provided marginal effects similar to the ones obtained with the linear versions. 6 some individuals who receive income from both selfemployment and wage work in some months are counted as self-employed. excluding these observations provides almost identical results. using the one-month lag of the self-employment indicator, or all lags up to the third or the twelfth, for example, gives estimated total effects of selfemployment with the same sign and level of statistical significance, differing only slightly in magnitude. this shows the stability of the self-employment indicator, as individuals rarely change type of work more than once over the seven-year period considered. we are interested in the overall effect of self-employment and not in the time dynamics. that overall effect can be captured by any single lag, given the high correlation between adjacent lags. furthermore, using more than one lag would result in many more observations being lost. in conclusion, β 1 gives the effect of being self-employed, as opposed to being a wage worker, on the likelihood of being hospitalized in the following month. the four specifications that we consider are the following: model 1 controls for the individual's gender, age group (18-25, 26-35, 36-45, 46-55, or 56-65) , nationality (portuguese or foreign), and place of residence (one of the 18 districts in the mainland or one of the 11 islands), 7 included in x i,t . we also include fixed effects for each month in the sample, denoted by τ t (84 months minus jan 2005, due to the lag, and feb 2005, which is the reference month). model 2 takes advantage of the longitudinal nature of the dataset and includes also individual fixed effects, denoted by μ i , to control for time-invariant individual unobserved heterogeneity. still, it is possible that endogeneity due to unobserved individual characteristics that vary over time remains, as discussed in the introduction. to tackle this potential threat, in addition to the individual fixed effects, we employ an instrumental variable strategy. thus, model 3 applies instrumental variables without controlling for individual fixed effects (i.e., instrumental variable estimation of model 1), and model 4 applies instrumental variables controlling for individual fixed effects (i.e., instrumental variable estimation of model 2). in sum, models 1 and 3 treat the data as pooled cross-sections, whereas models 2 and 4 are fixed effects panel data models; models 3 and 4 apply an instrumental variable strategy. we use two instruments. instrument one is the proportion of self-employed workers in individual i's district, excluding her municipality of residence, in the same month (see online resource 1 for the division of the portuguese territory into districts and municipalities). instrument two is the proportion of selfemployed workers of the same gender and age group of individual i in the whole country, also excluding her municipality of residence, in the same month. the proportion of workers in a given district or gender-age group who are self-employed captures the structure of the labor market in that area or demographic group. for example, there may be a predominant industry in a given district that relies on wage workers, or there may be a new service expanding where young self-employed women abound. in general, we expect that the larger that proportion, the higher the likelihood that any individual i residing in district j or belonging to gender-age group m is self-employed. however, in some cases, low self-employment in the district/demographic group may signal opportunities or conversely, high selfemployment may signal a saturated market. that is, some individuals may be defiers, responding in the opposite way to a higher proportion of self-employed workers in the district/demographic group (i.e., violation of the monotonicity assumption). when there are defiers, the two-stage least squares estimator gives a weighted difference between the effect of the treatment among compliers and defiers, which could be misleading. nevertheless, de chaisemartin (2017) derives a weaker condition under which the two-stage least squares estimator still provides a local average treatment effect (late) for "surviving compliers." with binary outcomes, like is our case, that condition holds if defiers' late and the two-stage least squares coefficient are both of the same sign, or if defiers' and compliers' lates are both of the same sign and the ratio of these two lates is lower than the ratio of the shares of compliers and defiers in the population. in this context, it is difficult to assess if that condition is likely to hold, because the effect of self-employment on the likelihood of hospitalization can be positive or negative. still, we see no reason for the lates of compliers and defiers to differ significantly, especially since fixed effects capture individuals' intrinsic characteristics that may explain why they respond differently to the instruments. so, we argue that the condition holds as the ratio of compliers to defiers should exceed the ratio of the two lates. 8 the proportion of self-employed workers in an individual's geographical area has previously been used to instrument self-employment decisions (e.g., noseleit 2014) . the novelty here is that instead of considering the proportion of self-employed workers in the individual's municipality, we consider only neighboring municipalities excluding the individual's own. this approach to devise instrumental variables has been employed, e.g., in autor et al. (2013) and nevo (2001) . in both our instruments, the exclusion of the individual's own municipality contributes to eliminate concerns regarding instrument exogeneity. overall, we believe our instruments are validly excluded from the main equation conditional on the remaining explanatory variables (i.e., they impact hospitalizations solely through their impact on the likelihood of self-employment). for instance in the case of the proportion of self-employed workers in the district (instrument one), the crucial explanatory variables are the district fixed effects. district fixed effects take into account any district characteristics that correlate with both the instrument and the outcome, hospitalizations, as long as those characteristics are constant over time. to explore this issue further, we look at the evolution over time of some district characteristics: a general income index, a general health index, and a firm dimension index, which are composite indices produced by a portuguese polling firm, marktest (online resource 2). what we observe is that all of those indices are fairly constant over time; therefore such characteristics should be appropriately captured by the district fixed effects. note also that by comparison, the proportion of self-employed workers in the district exhibits some within-district variation, so the instrument is relevant even when controlling for district fixed effects (online resource 2). with two instruments and one potentially endogenous variable, we are able to test statistically the validity of the overidentifying restriction. given that the endogeneous variable, self-employed i,t−1 , is lagged, we also use the lags of the instruments. as mentioned previously, our main analyses focus on the subsample that includes only individuals who switch between wage work and self-employment at least once over the sample period ("switchers"). after all, those are the individuals that are used for identification in the models with individual fixed effects. moreover, in the instrumental variables model with individual fixed effects, non-switchers are by definition non-compliers, and non-compliers reduce the instruments' statistical power (de chaisemartin 2017). we also present results for all model specifications for the entire sample, for comparison. lastly, standard errors are robust to heteroscedasticity and to clustering at the individual level in models 1 and 2, and at the district level in models 3 and 4 (because that is the level of observation of instrument one). the main time-varying unobserved individual characteristic that may affect both self-employment and the likelihood of hospitalization is health. unfortunately, we do not have information on health status; only hospitalizations. we construct an indicator variable that takes value one if the individual had any hospitalization in the previous three months, to try to capture any recent (serious) changes in health status. this variable is potentially not enough to fully rule out endogeneity, which is why we resorted to instrumental variables models. still, as a sensitivity check, we add this variable to model 2 as a control. we also compare the effect of self-employment on the likelihood of hospitalization for women versus men, individuals up to 35 versus 36 and more years old, and nationals versus foreigners. to do this, we include interaction terms between the lagged selfemployment indicator and the respective demographic dummies. since we have two instruments, we are able to instrument both the lagged self-employment indicator and the interaction term. we repeat the main analyses using quarterly rather than monthly data and compare the magnitudes of the estimates. aggregating the data in this way reduces total sample size to about one third. to shed further light on the types of hospitalizations of self-employed and wage workers, we obtained information on hospitalizations from the national diagnosis-related groups dataset. this allowed us to learn the main diagnosis underlying each hospitalization as well as if it was planned or not, but only for about half of the hospitalizations in the social security dataset that we could match indirectly, as there is not an individual identifier to fully merge the two datasets. these complementary analyses are detailed in the online resource 3. we also apply the model specifications described in the previous section to study the impact of selfemployment on the length of hospitalization. first, in a two-part model type of approach, we restrict the sample to individual-month observations with a hospitalization. we use the natural logarithm of hospitalization days as the dependent variable to account for the skewness in the distribution of hospitalization days. this approach drastically reduces the sample size. we compare the results, qualitatively, to those obtained for the full sample, using the natural logarithm of hospitalization days plus one in order to keep the zeroes. our data also allow us to investigate mortality. to explore the effect of self-employment on mortality, we aggregate the data to the person-year level, as we know the year but not the month in which the individual passes away. we create a binary dependent variable that takes value one if individual i passes away in year t + 1 and zero otherwise, while excluding observations for the year in which the person passes away. we compare results obtained when the self-employment indicator takes value one if the individual is selfemployed during at least one, six, or all twelve months of year t. we estimate the same model specifications as described in the previous section, adjusted for the annual frequency considered here. control variables are measured in year t. we discuss results for the subsample of individuals who switch at least once between self-employment and wage work over time ("switchers"). results for the full sample are also presented for comparison, in the bottom half of the tables (panel b). descriptive statistics by type of employment in the previous month are shown in table 1 . looking at the switchers, the self-employed account for 38.29% of the person-month observations (panel a). the average monthly rates of hospitalization of self-employed and wage workers are 0.06% and 0.14% respectively. note that these seemingly very low numbers correspond to monthly, not annual, hospitalization rates. the average number of days of hospitalization, conditional on there being any, is slightly larger among the self-employed: 12.86 compared with 11.05 days for wage workers. the differences in the rates and lengths of hospitalization over time in both samples are shown in the online resource 4. the proportion of women is slightly lower among the self-employed than among wage workers (50% versus 52%), the self-employed are on average slightly older (about 37 versus 36 years old), and the proportion of foreigners is also slightly lower among the self-employed (13% versus 14%). the proportion of self-employed workers in the district (instrument one) is on average 4.69% and varies between 0 and 17.74%. the proportion of self-employed workers in the same gender-age group in the country (instrument two) is on average 4.06% and varies between 0.75 and 17.34%. table 2 shows the results of models 1-4. starting with the first-stage results, we conclude that when the proportion of self-employment in the district or demographic group increases, the individual likelihood of self-employment also increases, as expected. specifically, when the proportion of self-employed workers in a given district (/demographic group) is one percentage point higher, the likelihood of any individual in that district (/demographic group) becoming selfemployed is about 7 (/4.5) percentage points higher, on average (panel a, model 4). 9 returning to why we focus on the subsample of switchers, as noted, e.g., by de chaisemartin (2017), non-compliers reduce the instruments' statistical power. in the instrumental variables model with individual fixed effects, non-switchers are by definition non-compliers. judging from the large fand t-statistics, the instruments appear strong when considering the full sample (panel b, model 4). however, looking at the second stage, we can see that the coefficient on the self-employment indicator is implausibly large in absolute terms, and has a huge standard error as well. this suggests that the instruments may actually not be strong enough even though the f-and t-statistics are above conventional thresholds. 10 therefore, we focus our discussion on the results for the sample of switchers. note that even in model 2, which includes individual fixed effects but not instrumental variables, identification of the effect of self-employment also comes from switchers. as for the instrument validity test, the null hypothesis is not rejected in any case. there is also no evidence of endogeneity. in fact, the coefficients on the self-employment indicator in the instrumental variables models (models 3 and 4) are very similar to the coefficients in models 1 and 2, except they are less precisely estimated and not statistically significant (panel a). 11 in light of this result, unobserved individual characteristics, in particular those that vary over time (e.g., health status), and reversed causality don't seem to pose an issue in our analyses. this is possibly because hospitalization is a fairly objective and a rare/extreme outcome, which doesn't capture health in general but serious (unexpected) manifestations of illness. furthermore, the estimated coefficient on the self-employment indicator is about the same whether or not individual fixed effects are included (model 1 versus model 2), suggesting that self-selection of the healthy into self-employment has no impact on don't respond to changes in the labor market as captured by the instruments. recall that in the full sample, only 4.24% of the observations are self-employed; in the subsample of switchers, this proportion increases to 38.29% (table 1) . the difference in effect size of the instruments when looking at the full sample versus the subsample of switchers can be interpreted in relation to these proportions of self-employment in each sample. 10 in the model without individual fixed effects, instrument one actually has a small t-statistic and the f-statistic is also small (panel b, model 3). 11 instrumental variables estimation using only instrument one or instrument two produces identical results. the negative association between self-employment and likelihood of hospitalization. lastly, controlling for any hospitalization in the previous three months, which is another (partial) way to address endogeneity, does not change the estimated coefficients from model 2. standard errors in parentheses, robust to heteroscedasticity and to clustering at the individual level in models 1 and 2 and at the district level in models 3 and 4. *p < 0.1, **p < 0.05, ***p < 0.01 the coefficient of the self-employment indicator was multiplied by 100 to facilitate reading we find that self-employed individuals are about 0.08 percentage points less likely than wage workers to be hospitalized in any given month. this is the same as the unadjusted difference in hospitalization rates of self-employed and wage workers observed in table 1 . compared with the average monthly hospitalization rate of 0.14% among wage workers, this means that self-employed individuals are less than half as likely to be hospitalized. overall, our findings indicate a large negative impact of self-employment on the likelihood of hospitalization that is consistent across models. results also indicate that female, older, and native workers have higher rates of hospitalization (results available upon request). looking at potentially heterogeneous effects of selfemployment for different subgroups, we find that the negative impact of self-employment on the likelihood of hospitalization is stronger for women than for men. there are no differences between individuals less than or 36+ years old or between nationals and foreigners (table 3) . using quarterly data gives negative and strongly significant coefficients, which are roughly three times as large as the coefficients in the main analysis, as expected (not shown). results from our exploration of the types of hospitalizations of self-employed and wage workers, detailed in the online resource 3, indicate that selfemployment is associated with lower likelihood of hospitalization for any underlying health problem, as well as whether hospitalizations are urgent or planned. looking at the natural logarithm of hospitalization days, conditional on there being a hospitalization, we find no significant effects of self-employment. however, this analysis is limited because only observations with a hospitalization are used and many individuals have only one hospitalization over the entire period of analysis. when including the zeroes, by looking standard errors in parentheses, robust to heteroscedasticity and to clustering at the individual level *p < 0.1, **p < 0.05, ***p < 0.01 the coefficient of the self-employment indicator was multiplied by 100 to facilitate reading at the logarithm of hospitalization days plus one, the estimated coefficients are negative and strongly significant, indicating that self-employment reduces the length of hospitalization by almost 0.2%. however, this analysis is also limited because the choice of adding one to the number of days, in order to keep the zeroes, may influence results. in sum, we find no evidence that a lower likelihood of hospitalization among self-employed individuals comes at the expense of longer lengths of hospital stays, which would suggest that self-employed individuals delay going to the hospital until they are more severely sick (results available upon request). table 4 presents the effect of self-employment on the likelihood of mortality in the following year. the self-employment indicator takes value one if the individual is self-employed for more than six months in the current year. similar results are obtained when standard errors in parentheses, robust to heteroscedasticity and to clustering at the individual level in models 1 and 2 and at the district level in models 3 and 4. *p < 0.1, **p < 0.05, ***p < 0.01 the coefficient of the self-employment indicator was multiplied by 100 to facilitate reading one month as a self-employed worker is enough to classify an individual as self-employed in year t or when we require individuals to be self-employed during the whole year. the models that (partly) address endogeneity provide negative coefficients for the selfemployment indicator (models 2-4). although not statistically different from zero, the estimated coefficient from model 2 indicates that self-employed individuals are about 0.01 percentage points less likely to die in the following year than wage workers. compared with the average mortality rate of wage workers, this represents a lower likelihood of mortality by about one third. this analysis has limitations, as data are aggregated to a yearly frequency and mortality is such a rare and extreme outcome that there is little variation to identify precisely an effect of self-employment. yet, results are in line with our main findings for hospitalizations, suggesting a protective effect of selfemployment when it comes to acute events such as hospital admission and death. it is probably as challenging as it is important to determine whether self-employment is good or detrimental for health. the potential self-selection of the healthy into or out of self-employment (and their typically small businesses) is difficult to rule out empirically. however, separating the effect of self-employment on health from that selection effect is crucial to inform policy decisions. moreover, informing policy is increasingly pressing these days, as new forms of self-employment emerge and the small businesses that they create can have a significant impact on sustainable economic growth. the ongoing covid-19 crisis may also represent a significant push towards selfemployment (and wage employment with increased job flexibility, through greater use of remote work) which may have its own additional consequences in terms of health. given the motivation above, we seek to provide causal evidence on the impact of self-employment on hospitalizations in this study. we take advantage of the longitudinal nature of our rich data, where we track roughly 6,500 individuals that switch between forms of employment over a period of up to 84 months. on top of that, we also employ an instrumental variable strategy to deal with any remaining endogeneity. we find that self-employed individuals are 0.08 percentage points (or about half) less likely to be hospitalized in a given month when compared with wage workers. qualitatively, this result is in line with most available evidence, which tends to find that self-employment is good for health. this includes toivanen et al. (2016 toivanen et al. ( , 2018 , who like us look at hospitalizations and mortality. we do not seem to find evidence of endogeneity, contrary to rietveld et al. (2015) , who find a negative association between selfemployment and health that is fully explained by a selection effect. the different results between the two studies may be due to the type of outcomes considered and samples used. while we focus on administrative records of hospitalizations and consider the whole working population, rietveld et al. (2015) draw on survey-based subjective health measures and focus on the 50+ population. hospitalization is a specific, acute outcome and not a measure of health status per se. the same can be said of mortality. the job demand-job control theory is closely linked to work-related stress, yet the most obvious manifestations of stress do not always lead to hospitalization or death (e.g., anxiety, depression). in this regard, we may miss important impacts of self-employment on health, which can be positive or negative. we believe more research is needed on this important topic, looking at different, complementary health outcomes. nevertheless, as mentioned in the introduction, stress is an important cause of many health problems, ranging from cardiovascular to respiratory, digestive, and other troubles, which frequently lead to hospitalization (or death). in our analyses of the health problems underlying hospital admissions, we find that self-employed individuals are particularly less likely than wage workers to be hospitalized for troubles of the cardiovascular, respiratory, and digestive systems. despite the limitations of those analyses, our results do not contradict the interpretation that self-employed individuals seem to suffer from lower stress than wage workers or, in other words, that the beneficial effects of higher job control when selfemployed exceed the detrimental effects of higher job demands. our results are also consistent with the research on "procedural utility" that finds higher levels of well-being among self-employed individuals, something that may be linked with lower stress/better health. our results may also reflect changes in the occupations when individuals switch to/from selfemployment and small businesses, which may have different exposures to occupational hazards. for instance, manufacturing workers-typically wage workers-may be more prone to injuries at work. we do find that self-employed individuals are significantly less likely than wage workers to be hospitalized for troubles of the musculoskeletal system, which include many work-related episodes. still, we find equally large or larger differences in hospitalization rates for other types of troubles. unfortunately, with the available data we cannot explore this issue precisely, as we do not know the industry/occupation of self-employed individuals. the potentially different effects of self-employment by industry remains a topic that deserves to be explored in future research. toivanen et al. (2016) and toivanen et al. (2018) already showed promising results in this regard. we believe that the premiss that self-employed individuals may delay care in order not to lose business is of limited concern here. hospitalizations are generally acute, untimed events. furthermore, non-emergency acute interventions are scheduled by the hospital and long waiting lists deter individuals from passing on a scheduled intervention they need. we find identical relative risk ratios for urgent and planned hospital admissions. also, if self-employed individuals, having more limited access to sickness benefits, delayed appropriate care until they are seriously sick and have to be hospitalized, we would find that self-employment leads to higher rates of hospitalization, which is the opposite of what we find. as we do not know the diagnoses of all hospital admissions in the data, we cannot exclude admissions related to pregnancy and childbirth, which are unrelated to health status and capture instead fertility decisions. however, while this may partly explain the larger effect of self-employment found for women, it does not explain our findings for men, for whom we also find negative hospitalization effects. with our approach, we were able to at least partly rule out endogeneity, thanks largely to the rich longitudinal dimension of the data we use. further research may want to explore additional individual information to investigate potential heterogeneous effects, e.g., by industry or occupation. further research may also want to consider the case of self-employed individuals with employees, even if this type of self-employment and their small businesses is less common among platform economy jobs. in conclusion, this study provides evidence of a positive impact of self-employment on health and does so by focusing on an objective outcome-hospital admissions-that is not subject to recall or other biases that may affect previous studies. the positive health effect we document may be at least partly explained by greater control by the individual over different aspects of the working life associated with this form of small businesses. one important dimension of the ongoing debate about the "future of work" is precisely how to increase protection for workers under flexible contracts, such as those that increasingly emerge in the platform economy (e.g., garben 2017 , european commission 2017 . this dimension is now even more significant in the context of the covid-19 crisis. this may also involve multiple policy aspects such as social security, employment law and collective bargaining. our results indicate that, despite the existing concerns, at least as far as significant health events are concerned, there are important social gains from more flexible work formats. furthermore, as the platform economy grows around the world, leading to increasing shares of the workforce in self-employment, causal evidence about the health implications of that type of work becomes more pressing. the 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neurobiology of stress and gastrointestinal disease measuring market power in the ready-to-eat cereal industry self-employment can be good for your health female self-employment and children platform workers in europe. evidence from the colleem survey. luxembourg: publications office of the european union stress, satisfaction, and the work-family interface: a comparison of selfemployed business owners, independents, and organizational employees selfemployment and health: barriers or benefits? why the self-employed are happier: evidence from 25 european countries health of entrepreneurs versus employees in a national representative sample stress and cardiovascular disease current issues relating to psychosocial job strain and cardiovascular disease research mortality differences between selfemployed and paid employees: a 5-year follow-up study of the working population in sweden s eloranta. hospitalization due to stroke and myocardial infarction in self-employed individuals and small business owners compared with paid employees in sweden -a 5-year study small business owners and health o trabalho por conta própria em portugal. instituto nacional de estatística the effect of self-employment on health, access to care, and health behavior transitions to selfemployment at older ages: the role of wealth, health, health insurance and other factors publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-266342-9iql8yib authors: kokkoris, michail d.; stavrova, olga title: staying on track in turbulent times: trait self-control and goal pursuit during self-quarantine date: 2021-02-15 journal: pers individ dif doi: 10.1016/j.paid.2020.110454 sha: doc_id: 266342 cord_uid: 9iql8yib prior research has shown that routines and beneficial habits largely explain high self-control people's success at goal pursuit. however, covid-19 self-quarantine measures and country-level lockdowns have largely challenged people's ability to stick to their daily routines and habits. how successful at goal pursuit are people with high self-control when the world around them is not as it used to be? we examined if self-control passes the ‘quarantine test’. in an online study (n = 271), we measured trait self-control, goal progress, continued engagement in pre-pandemic goal-directed behaviors, development of new goal-directed behaviors and turning these new behaviors into habits. results showed that during lockdown, people with higher (vs. lower) trait self-control were not only more likely to continue engaging in pre-pandemic goal-directed behaviors, but also found it easier to develop new goal-directed behaviors and were more likely to turn these behaviors into habits. high self-control people's ability to continue performing pre-pandemic goal-directed behaviors and to turn new behaviors into habits explained their success at goal attainment despite the major disruptions caused by the pandemic. quarantine measures implemented to fight the covid-19 pandemic have radically changed the lives of millions of people worldwide. besides having various negative consequences for psychological wellbeing (brooks et al., 2020; rajkumar, 2020; rodriguez, litt, & stewart, 2020) , quarantine measures are likely to pose major challenges to personal goal pursuit because they disrupt people's daily routines and make it hard or even impossible to continue engaging in behaviors people used to engage in to reach their goals. people's struggle to stay on track and keep pursuing their goals despite major upheavals in almost all spheres of life has been often addressed in the popular press (samuel, 2020; times staff, 2020) . what predicts individuals' ability to stay on track and stick to their goals despite major disruptions in their lives? the literature has long identified a personality trait that predicts successful goal pursuit: self-control. people with higher (vs. lower) selfcontrol are more successful at reaching their goals across various life domains, including health, well-being, relationships, academic, career, financial and others (de ridder, lensvelt-mulders, finkenauer, stok, & baumeister, 2012; tangney, baumeister, & boone, 2004) . herein, we asked whether trait self-control also passes the 'quarantine test': using the covid-19 pandemic as a natural laboratory to study goal pursuit under exceptionally disruptive circumstances, we examined whether trait self-control is associated with more goal progress. prior research on self-control has shown that one of the reasons why people with higher (vs. lower) self-control are more successful at goal attainment is because they use adaptive behavioral strategies, such as turning goal-directed behaviors into habits (adriaanse, kroese, gillebaart, & de ridder, 2014; de ridder & gillebaart, 2017; ent, baumeister, & tice, 2015; galla & duckworth, 2015; stavrova, pronk, & kokkoris, 2020; stavrova, pronk, & kokkoris, 2019) . this tendency to develop "beneficial habits" could facilitate goal attainment during selfquarantine for high self-control individuals. herein, we examined whether during the pandemic people with higher (vs. lower) trait selfcontrol were more likely to stick to their "beneficial habits" and continue engaging in behaviors they had developed to reach their goals prior to the pandemic. at the same time, regardless of whether high self-control people were more likely to continue engaging in their pre-pandemic goal-directed behaviors, it is intriguing whether self-control promotes flexibility and the ability to develop new goal-directed behaviors to adapt to the current situation as well. developing new adaptive strategies might be necessary for goal pursuit when external circumstances change and existing routines may no longer serve one's goals. although it has been argued that self-control might also be instrumental in the https://doi.org/10.1016/j.paid.2020.110454 received 22 july 2020; received in revised form 6 october 2020; accepted 11 october 2020 ⁎ corresponding author. t development of new habits (e.g., wood, 2016) , there has not been much empirical research examining the relation between self-control and new habit formation. the covid-19 pandemic provides a very suitable context for the study of initial formation of beneficial habits. thus, we investigated whether people with higher self-control would be more flexible to adjust to the new situation, would find it easier to develop new behaviors to reach their goals and would be more likely to turn these behaviors into habits that support their goal pursuit. in sum, we used the covid-19 pandemic as a context to examine whether people with higher (vs. lower) self-control made more progress towards their goals, and whether they did so by continuing performing their pre-existing goal-directed behaviors and/or by being more flexible and able to develop new behaviors and turn them into habits. participants were 271 undergraduate students (147 women, 18-35 years old, m = 21.68, sd = 2.81) recruited via the subject pool of a large european university for course credit. a sensitivity power analysis showed that this sample size can reliably detect effect sizes of ρ = 0.17 (two-tailed) with an alpha level of 0.05 and power of 0.80. the study was conducted online from june 8 to 16, 2020. after an explanation of what goals are (stavrova et al., 2019; stavrova et al., 2020) , participants were asked to write down one personal goal that they had started pursuing before the lockdown and that they still wanted to achieve. then, they wrote down up to five behaviors they had been using to achieve this goal before the lockdown started. for each behavior, they indicated to what extent they were able to continue performing it after the lockdown started (α = 0.68; 1 = not at all; 7 = very much). participants were also asked whether they had developed any new behaviors to achieve their goals after the lockdown started (yes/no), and if yes, to write down up to five of them. for each one of the new behaviors, they indicated how easy it was to develop this behavior (α = 0.67; 1 = not at all; 7 = very much) and to what extent it had already become a habit for them, i.e. part of their daily routine (α = 0.69; 1 = not at all; 7 = very much). goal progress was assessed with three items (α = 0.80) adopted from milyavskaya and inzlicht (2017) ; e.g., "i feel like i'm on track with my goal plan"; 1 = strongly disagree; 7 = strongly agree). in addition, participants filled out a measure of flexibility regarding their overall response to the covid-19 crisis, which we developed for the purpose of this study. it comprised the following five items (α = 0.80): "i accepted the challenge to reconsider my routines," "i responded to the demands of the situation with flexibility," "i tried to adjust to the new situation as best as i could," "i discovered new ways of doing things," and "i found alternative solutions to my problems" (1 = not at all true; 7 = very true). finally, trait self-control was measured with the brief self-control scale (tangney et al., 2004) , which comprises 13 items (α = 0.83; e.g., "i am good at resisting temptation"; 1 = not at all like me; 7 = very much like me). self-control was measured in counterbalanced order at the beginning or the end of the questionnaire. descriptive statistics and inter-correlations of all variables are presented in table 1 . inspection of correlations between self-control and self-reported flexibility in the response to covid-19 crisis showed that people with higher self-control reported a higher overall flexibility, r (268) = 0.28, p < .001. next, we examined whether this perception of flexibility reported by high self-control people is reflected in their ability to continue performing goal-directed behaviors developed before the pandemic and/or develop new behaviors to pursue their goals despite the pandemic-caused disruptions. on average, participants reported 3.87 behaviors (sd = 1.21, min = 1.00, max = 5.00) that they had been using to reach their goals before the lockdown started. the number of behaviors reported was uncorrelated with trait self-control, r = 0.00, p = .961. however, during the lockdown, people with higher (vs. lower) trait self-control were more likely to continue engaging in behaviors they had developed to reach their goals prior to the lockdown, r(268) = 0.25, p < .001. as our data have two levels, with participants (level 2) being able to report multiple behaviors (level 1), we additionally analyzed the data using multilevel regression. multilevel regression is particularly suitable here as it accounts for the non-independent data structure (behaviors nested within participants) by modelling participants as random (i.e., including a random intercept at the level of participants; hox, 2002) . all variables were standardized before the analyses, so that the parameters can be interpreted as standardized coefficients. we used lme4 package (bates, maechler, bolker, & walker, 2015) in r. consistent with the correlation analyses reported above, trait self-control was positively associated with the ability to continue performing prepandemic goal-directed behaviors during the lockdown, β = 0.18, p < .001. among all participants, 42.1% (n = 114) started new behaviors to reach their goals during lockdown. starting new behaviors (dummycoded, 1 = yes) was uncorrelated with trait self-control, r(268) = 0.05, p = .443. that is, people with higher self-control were not more or less likely to have developed new behaviors to reach their goals. if we examine only the group of participants who have started new behaviors, we can see that they reported to have started on average 2.62 new behaviors (sd = 1.42, min = 1.00, max = 5.00). moreover, among these participants who developed new behaviors, the number of new behaviors reported was again uncorrelated with trait self-control, r = 0.06, p = .529. that is, people with higher self-control were not more or less likely to report more new goal-directed behaviors. however, people with higher self-control found it easier to develop new behaviors, r(112) = 0.32, p = .001, and were more likely to report that these behaviors have already become habits, r(112) = 0.20, p = .032. multilevel regression results supported these conclusions: self-control was positively associated with the ease of developing new goaldirected behaviors, β = 0.23, p = .001, and the perception that the new behaviors have become habits, β = 0.17, p = .031. people with higher self-control reported more progress towards their goals, r(268) = 0.26, p < .001. we further explored whether the ability to stick to pre-pandemic goal-directed behaviors, the perceived ease of developing new goal-directed behaviors or the ability to turn new behaviors into habits explain high self-control individuals' success at goal attainment. we used parallel mediation analyses with the three variables (average values across the reported goal-directed behaviors) as parallel mediators. the results of the mediation are shown in fig. 1 . the indirect effects of the ability to continue pre-pandemic goal-directed behaviors and to turn newly developed behaviors into habits were significant mediators. that is, trait self-control predicts goal attainment as it is associated with both sticking to pre-pandemic goaldirected behaviors and turning new goal-directed behaviors into habits. developing structures, routines and beneficial habits explains high self-control people's success at goal attainment (adriaanse et al., 2014; de ridder & gillebaart, 2017; ent et al., 2015; galla & duckworth, 2015; stavrova et al., 2020; stavrova et al., 2019) . is this also true during challenging times such as the covid-19 pandemic? our results showed that self-control passes the 'quarantine test': individuals higher (vs. lower) in self-control made more progress towards reaching their goals during quarantine. this was explained both by continuing prepandemic goal-directed behaviors and by turning newly developed goal-directed behaviors into habits. this finding adds to prior literature by showing that the benefits of high self-control persist under uniquely disruptive circumstances. even though the world had changed dramatically, high self-control people demonstrated a remarkable capacity to stick to pre-existing habits and had the flexibility to develop new habits that better met situational demands. the combination of these two -maintaining past habits and developing new ones -is high self-control people's recipe for success in turbulent times. a practical implication of our findings is that interventions aimed at increasing self-control may be beneficial also in the context of the challenges posed by the covid-19 pandemic. further research using objective measures of goal attainment, longitudinal data and non-student populations is needed to corroborate these insights. effortless inhibition: habit mediates the relation between self-control and unhealthy snack consumption fitting linear mixed-effects models using lme4 the psychological impact of quarantine and how to reduce it: rapid review of the evidence lessons learned from trait self-control in wellbeing: making the case for routines and initiation as important components of trait self-control taking stock of self-control: a meta-analysis of how trait self-control relates to a wide range of behaviors trait self-control and the avoidance of temptation more than resisting temptation: beneficial habits mediate the relationship between self-control and positive life outcomes introduction to mediation, moderation, and conditional process analysis: a regression-based approach multilevel analysis: techniques and applications what's so great about self-control? examining the importance of effortful self-control and temptation in predicting real-life depletion and goal attainment covid-19 and mental health: a review of the existing literature drinking to cope with the pandemic: the unique associations of covid-19-related perceived threat and psychological distress to drinking behaviors in american men and women quarantine has changed us -and it's not all bad choosing goals that express the true self: a novel mechanism of the effect of self-control on goal attainment finding meaning in self-control: the effect of self-control on the perception of meaning in life high self-control predicts good adjustment, less pathology, better grades, and interpersonal success 44 life-changing habits you don't want to give up after the pandemic handbook of self-regulation: research, theory, and applications key: cord-017217-zjab7o2o authors: ali, yousaf title: self assessment questions date: 2008-01-08 journal: self assessment questions in rheumatology doi: 10.1007/978-1-59745-497-1_1 sha: doc_id: 17217 cord_uid: zjab7o2o nan this is a common inpatient scenario. a stable patient with renal failure is admitted and undergoes a stressful procedure that triggers gout. treatment of acute gout involves high-dose nsaid, colchicine, or corticosteroids. in a patient with renal failure and diverticular inflammation, nsaids and colchicine should be avoided since they are poorly tolerated. a monoarticular presentation could be injected with local intraarticular corticosteroid assuming that the cultures are negative. in this patient with polyarticular gout a short burst of oral corticosteroid is the best option. uric acid levels fall and are often normal during an attack and should not be used as a diagnostic test. terkeltaub ra. clinical practice. gout. n engl j med. 2003 oct 23; 349(17) :1647-55. this is a rare but important complication of ss. distal rta occurs due to failure to acidify urine to a ph < 5.3. this results in anion gap acidosis, hypokalemia, nephrocalcinosis, and bone demineralization. the lymphocytes that invade the tubular epithelial cells are cd8-positive, i.e., cytotoxic t cells and similar to those found in the salivary glands of patients with sjögren's syndrome. the same immunological process is probably operative in the renal tubulointerstitial tissue as in the salivary glands to induce the characteristic tissue changes of sjögren's syndrome. matsumura a 47-year-old patient with crohn's disease presents for evaluation of new onset arthritis. she has a 20-year history of colitis managed with sulfasalazine and local corticosteroid suppositories. infliximab at 5 mg/kg was recently commenced due to persistent disease activity. she arrives with new onset polyarticular joint pain. on examination she has synovitis of the small joints of the hands and a warm knee effusion. lab work: wbc = 2.8, hb = 11.2 g/dl, platelets = 554, esr = 66, ana = 1:640, rf = 54, and renal and liver studies normal. what is the most likely diagnosis? what further tests can confirm this? how would you manage this patient? she has aggressive erosive disease with elevated markers of inflammation and hightiter ccp antibody. since she is actively symptomatic despite two diseasemodifying antirheumatic drugs (dmards) it is time to add methotrexate (mtx). triple therapy is superior to single agents although there are many pills to take weekly. a short bridge of corticosteroids may also be helpful in decreasing inflammatory symptoms. some rheumatologists will argue that aggressive early use of tumor necrosis factor (tnf) antagonists is also indicated. since these are expensive medications and the patient has not failed the "gold standard" they should be reserved unless she fails to respond to mtx. this algorithm may change as costbenefit data on the existing agents become available and as newer, safer, and more efficacious agents are introduced. a 68-year-old female is referred for diffuse joint pain and fatigue of 2 years duration. her pmh is consistent with depression, posttraumatic stress disorder (ptsd), and hypothyroidism. hematologic, biochemical, and immunologic studies are negative. inflammatory markers are not elevated. on examination she has palatal hypertrophy and is markedly obese. cardiac examination reveals a loud s2 with rv heave. pulmonary examination is normal. she has pitting edema and multiple tender points to palpation but no synovitis. what is the most likely diagnosis? what investigations, if any, are appropriate? how would you manage her? patients with chronic sleep apnea develop pulmonary hypertension due to hypoxemia and develop subsequent right-sided pulmonary hypertension. a distinct relationship exists between poor sleep quality and pain intensity. this patient most likely has fibromyalgia, which is characterized by widespread pain, insomnia, and tender points. investigations should focus around excluding an organic cause for pain, managing sleep disturbance, and treating underlying sleep apnea and depression. physical therapy, counseling, and aerobic exercise have also been found to be useful. amyloidosis is a systemic disease characterized by deposition of insoluble beta pleated sheets of protein in various organs. the diagnosis can be confirmed by congo red staining of subcutaneous fat. although it is primary amyloidosis that usually affects the myocardium it can also occur with the secondary form. his lower extremity edema might be explained by heart failure but nephrotic syndrome also needs to be excluded. treatment of secondary amyloidosis is often unsatisfactory and primarily involves treatment of the underlying disease. a 19-year-old female with sle consults you for contraceptive advice. she is sexually active and has a history of serositis, leucopenia, and arthritis. current medications include azathioprine 100 mg/daily and naprosyn 500 mg twice daily. labs: wbc = 2.4, hb = 10.5, platelets = 125,000, lupus anticoagulant present, ptt = 55 s, and anticardiolipin (aca) antibody igm/igg strongly positive. what advice would you give her regarding contraception? answer: she should be advised to use barrier protection, progesterone only pill or iucd's this patient has a prolonged partial thromboplastin time, thrombocytopenia, strongly positive aca's, and circulating lupus anticoagulant. although the patient has not had prior thromboses she is at high risk for developing antiphospholipid antibody syndrome in view of these blood tests. these patients are hypercoagulable and should not be given estrogen-containing products due to the increased risk of thrombosis. she should be advised to use barrier protection, progesterone-only pill, or iucds. acog recommends that in sle, estrogen-containing contraceptives be avoided in patients with vascular disease, nephritis, or aca. a 19-year-old previously healthy student is evaluated for new onset fever, joint pain, and rash. she is sexually active but denies diarrhea, urethral discharge, or sore throat. her symptoms occurred 1 week following her menses. there was no history of travel, tick bite, or prior joint symptoms. physical examination reveals a febrile patient with pustular lesions over the arms and tenosynovitis of the wrist. her immunologic and hematologic studies and renal parameters are normal. the laboratory calls to inform you of gram negative diplococci growing in the blood cultures. this patient has the classic arthritis-dermatitis syndrome characterized by tenosynovitis and purulent vesicles. dgi is more common in women, and menstruation appears to be an important risk factor. the diagnosis is established by culturing the blood, cervix, urethra, rectum, pharynx, and synovial fluid. the patient and her partner should also receive testing for chlamydia. treatment for dgi is an intravenous cephalosporin regimen (e.g., ceftriaxone 1 g iv every 8 h) until clinical improvement followed by an oral cephalosporin. a 77-year-old male is referred to you for the treatment of intercritical gout. his serum ua is 12.5 mg/dl and he has mild renal insufficiency with a serum creatinine of 1.6 mg/dl. allopurinol and once daily colchicine are prescribed. he calls your answering service 1 week later with new onset of fatigue and ecchymosis. what complication has occurred? yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 this condition occurs rarely and may be more common in patients with renal failure. allopurinol should be immediately discontinued and hematologic support instituted. although colchicine toxicity can also cause bone marrow failure this tends to occur with higher doses. a 35-year-old female is seen for follow-up of sjogrens syndrome due to persistent arthritis and parotitis. you consider starting azathioprine. she informs you that her sister took this medicine and had a "bad reaction with her blood." what tests should be ordered prior to commencing this drug? how common is this abnormality? a 31-year-old african american male is seen for evaluation of uveitis and bell's palsy. he has a low-grade fever, parotid gland enlargement, mild arthritis, and dyspnea on exertion. what is the most likely diagnosis? what treatment is indicated? this patient has sarcoidosis with involvement of the uveal tract and parotid gland. ninety percent of patients with sarcoidosis have pulmonary involvement, and further evaluation should include chest radiography with pulmonary function testing. the goal of treatment is to decrease inflammation and the mainstay of treatment is corticosteroids. ocular inflammation often responds to topical steroids. sarcoidosis is often a self-limiting disease. a 76-year-old male is referred for further management of ankylosing spondylitis. he was told he had a "bamboo spine" on routine cxr. he emphatically denies stiffness, pain, or enthesopathy. his examination shows slightly limited spine flexion, normal chest excursion, and wall-to-occiput distance of 2 in. inflammatory markers are not elevated and he had no history of ocular disease or adolescent back pain. what is the most likely diagnosis? what other tests will facilitate the diagnosis? what treatment is advised? answer: 1. diffuse idiopathic hyperostosis syndrome (dish). it is very unlikely that the patient has ankylosing spondylitis (as). as typically affects young men in the second and third decade of life and is characterized by stiffness of the axial skeleton and sacroiliac joints. this elderly gentleman most likely has dish syndrome, which is a condition that involves flowing ossifications along the anterolateral aspect of four contiguous vertebra. it is of unknown etiology but usually involves the thoracic spine. a 73-year-old male is referred for evaluation of refractory lower extremity edema. he has had slight stiffness in the proximal areas but is more concerned about his leg swelling. he denies headaches/jaw claudication or visual changes. on examination he has small joint synovitis and 3+ pitting peripheral edema. there are no signs of heart failure. investigations reveal normal renal function and urinalysis. hb = 11.1 g/dl, esr = 45 mm/h. rf/ccp antibody are negative. ultrasound of the le reveals no evidence of venous occlusion. a two-dimensional echo is normal without pericardial or rightsided dysfunction. what is the most likely diagnosis? what treatment is advised? what is the prognosis? this patient has classic rs3pe with peripheral edema and symmetrical swelling but no evidence of ra. this is a rare condition that mimicks pmr and ra although there are no long-term consequences of joint damage or deformity. patients often have modestly elevated inflammatory markers and respond well to oral corticosteroids. prognosis is generally excellent. a 47-year-old female presents with arthralgia, rash, and parasthesias. her examination reveals palpable purpura and peripheral neuropathy but no synovitis. she denies xerostomia, sicca symptoms, renal disease, or recurrent sinusitis. her laboratory tests reveal modest transaminitis with low serum albumin, prolonged prothrombin time. ana is negative but rf is moderately positive. anca tests are negative. what is the most likely diagnosis? yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 this patient has evidence of chronic liver disease with decreased synthetic function. the constellation of palpable purpura, arthralgia, and neuropathy are highly suggestive of mixed croglubulinemia (mc). mc is quite common in hcv although only clinically apparent in about 10% of patients. it is also associated with membranoproliferative glomerulonephritis and vasculitis. hga is becoming a more commonly recognized cause of fever following a tick bite in the usa. the vector for this infection is the ixodes tick, which also carries the spirochaete responsible for lyme disease ( borrelia burgdorferi ). humans are affected when they impinge on small mammal/tick-infested areas. the common clinical presentation is fever, headache, and myalgia. arthralgias, septic shock, pancytopenia, renal failure, and acute respiratory distress syndrome (ards) are also rare complications. treatment is with oral doxycycline. coinfection with babesiosis and lyme disease can also occur and should be checked in symptomatic patients who live in endemic areas. a 44-year-old well-nourished caucasian female is referred for evaluation of a swollen knee. she has presented to the er on two occasions and had the knee drained. serial culture results are negative and no crystals have been observed. the effusions have been "bloody" although she denies trauma or anticoagulant use. she walks with a limp and is otherwise well without systemic complaints. on examination she has a swollen right knee with boggy synovial thickening and mild warmth. no other joints are involved. a knee radiograph is normal. lab tests including ana, rf, esr, and lyme serology are negative. hematologic studies are normal. the differential diagnosis for a hemarthrosis includes bleeding diathesis, trauma, pseudogout, charcot joint, and pvns. since her hematologic indices are normal and there has been no trauma; intraarticular hemorrhage or charcot joint seem less likely. pseudogout is typically seen in older patients with preexisting degenerative joint disease, metabolic disease, or hyperparathyroidism, and no crystals have been observed. pvns is a rare slow-growing benign tumor of the synovium with typical mri findings. treatment is arthroscopic synovectomy. her nourishment is relevant as scurvy can also cause recurrent hemarthrosis. a 78-year-old female is referred for treatment of osteoporosis. she has a history of breast cancer in situ without skeletal involvement, and esophageal reflux. axial t scores are −2.6, hip −2.7. on examination she has bilateral poor dentition and marked kyphoscoliosis. there is a history of hip and spine fracture. calcium, vitamin d, pth, and renal function are normal. her breast cancer is currently in remission. her gp has tried both residronate and alendronate, which caused gi distress. this patient is at a moderately high risk for future fracture. the most potent oral antiresorptive agents are bisphosphonates (bp), which have been shown to decrease incident vertebral and hip fractures. unfortunately, because of her esophageal disease she is a poor candidate for bps, which can cause gi distress. a selective estrogen modulator (serm) such as raloxifene would be a reasonable choice given her prior breast cancer although there are no data to support a reduction in hip fracture. teriperatide is an anabolic agent used in patients refractory to oral agents at high risk for fracture. it is given via the subcutaneous route and generally well tolerated in patients with esophageal issues. intravenous bisphosphonates should be avoided in this patient given the higher incidence of osteonecrosis of the jaw (onj) in patients with preexisting poor dentition, malignancy, diabetes, and nicotine use. a 46-year-old diabetic male has pain over the metacarpophalangeal (mcp) joints. he has about 15 min of morning stiffness. on examination he has swollen tender second/third mcp joints but no overt synovitis. serologies are negative and radiographs reveal hook-like osteophytes at the mcp and pip joints. what is the most likely diagnosis? what tests would you order? an elevated ferritin or transferrin saturation is suggestive of hemochromatosis. patients develop osteoarthritis of the second and third mcp joint, which may be the initial clue to the diagnosis. iron deposition occurs in the pancreas causing diabetes. occasionally, chondrocalcinosis is observed. this patient most likely has a pancoast's tumor causing hypertrophic pulmonary osteoarthropathy (hpoa). bronchogenic carcinoma is one of the causes of hpoa and results in periostitis and clubbing. although the cause is unknown, abnormal expression of vascular endothelial growth factor (vegf) has been described in this condition. a 78-year-old female is seen due to a swollen right shoulder. she denies having trauma or prior history of crystal arthritis. her shoulder examination reveals a large warm effusion with limitation of motion in all directions. a radiograph demonstrates advanced glenohumeral destruction but no calcification. arthrocentesis reveals a bloody effusion without evidence of infection or crystals on conventional polarized microscopy; cytology is negative. what test should you order from your laboratory that will most likely yield the diagnosis? this patient most likely has milwaukee shoulder due to the presence of calcium hydroxyapatite crystals. this condition is characterized by intrarticular or periarticular hydroxyapatite crystals causing a destructive arthropathy at the glenohumeral and rotator cuff interval. the cause is unknown. a 19-year-old female with sle presents with a new limp and right groin pain. one week prior to presentation she received high-dose intravenous corticosteroids for class iv glomerulonephritis. on examination there are no findings apart from irritation of the right hip with rotation. a pelvic and hip radiograph are normal. what is the most likely diagnosis? how would you manage the patient? yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 avn results in dead trabecular bone and marrow extending to involve the subchondral plate due to local ischemia. the highest incidence of avn of the hips occurs in patients with sle and renal transplants, who have been exposed to high-dose steroids. ultimately collapse of the femoral head occurs, which necessitates hip replacement. in early stage 1 avn plain radiographs are normal and so a high level of suspicion needs to be maintained. the patient should be evaluated by an orthopedist and avoid weight-bearing. core decompression should be considered depending on the severity of necrosis. since the risk of avn is greater in patients with hypercoagulability, antiphospholipid syndrome should be excluded. a 65-year-old female is referred by the gp due to an elevated creatinine phosphokinase (cpk). she has a history of obstructive sleep apnea, type 2 diabetes, and hypertension. there is no history of trauma, intramuscular injection, or dark urine. recently she was started on atorvastatin 20 mg daily. a routine blood test 1 month after the lab test revealed a cpk of 525 iu/ml (nl < 250); no baseline level is available. on examination, she is obese; weight 350 lb. there are no rashes, nodules, or muscle tenderness. muscle strength is 5/5 throughout what additional blood tests would you like to know? what management is indicated? this patient has a slightly elevated cpk level without symptoms of muscle breakdown or inflammation. given her obesity, the most likely scenario is that the cpk reflects her high muscle mass and is normal when calibrated for her bmi. this is a common scenario in practice and in the absence of weakness, rhabdomyolysis, or pain no specific treatment is indicated. given her cardiac risk factors she should continue the statin therapy and the cpk levels should be monitored closely. a tsh should be checked to exclude hypothyroid myopathy. renal function should also be checked as rhabdomyolysis is a serious complication of muscle breakdown and needs to be excluded. the absence of arthritis, raynaud's phenomenon , or rash makes a connective tissue less likely. a 28-year-old female patient is referred for osteoporosis. she has a 6-month history of weakness, myalgia, and 50-lb weight gain. three months prior, she fell and fractured her pelvis. pmh is unremarkable apart from poorly controlled hypertension. her menses are normal. she takes no medications apart from atenolol. lab work reveals k = 3.2 meq, normal renal and hematologic parameters. cpk, vitamin d, and malabsorption studies including celiac antibodies are normal. a bone dexa scan reveals an axial t score of −3.5 and hip t score of −3.3. corresponding z scores are both less than −2.0. her examination reveals a bitemporal hemianopsia, bp 155/95, obesity, and mild muscle tenderness. what is the most likely diagnosis? what is the optimal treatment? yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 excessive cortisol production from an acth-secreting tumor results in hypertension, hypokalemia, and accelerated osteoporosis. a large mass that extends into the suprasellar fossa can place pressure on the optic chiasma resulting in visual field defects. in this case prolonged exposure of cortisol has resulted in osteoporosis. a low z score below −2.0 raises the possibility of age inappropriate low bone mass. the treatment of choice for classic cushing's disease is surgical resection of the adenoma with the goal being to relieve pressure and preserve pituitary function. a 32-year-old teacher presents with refractory left-sided raynaud's and left-sided neck pain. she has no other serologic or clinical stigmata of a connective tissue disease. treatment with calcium channel blockers, aspirin, nitrates, and alpha blockers is ineffective. her examination reveals a diminished left radial pulse with inspiration. blood work is normal. what is the most likely diagnosis? yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 this young patient has unilateral evidence of vascular insufficiency in the upper extremity. in a nonsmoker the differential diagnosis includes raynaud's phenomenon or occlusion of the subclavian artery. usual causes of raynaud's phenomenon include idiopathic, hyperviscosity, atherosclerosis, connective tissue disease, or vasculitis. these are less likely in this case since the symptoms are unilateral. the patient has a positive adson's maneuver with a diminishing pulse on inspiration suggestive of a cervical rib or fibrous band. a cxr with apical lordotic view will show the cervical rib. you are asked to see a 22-year-old female from laos who is admitted as an inpatient. she presented with a febrile illness with quotidian spikes to 101°f. there is associated malaise and general weakness. there has been no recent travel out of the usa for over a year and no sick contacts, tick bites, or rash. on examination she is febrile, and there is diffuse shotty lymphadenopathy, splenomegaly, and bilateral warm knee effusions. her lab work reveals leukocytosis with lymphocytic predominance, normal renal function, mild transaminitis, and low serum albumin. urinalysis is normal with no proteinuria or cellular activity. microbiologic, viral, and rickettsial titers are negative. bone marrow studies are nondiagnostic and negative for mycobacteria. ct scans of abdomen, chest, and pelvis are normal. you order blood work: ana +1:40, rf negative, ccp negative, aso, parvovirus, and urine tests for gonorrhea are negative. esr is 115 mm, crp = 372 mg/dl, and ferritin = 4,500 ng/ml. what is the most likely diagnosis? how would you manage her? this patient has the classic features of aosd with spiking fever, organomegaly, derangement of liver function, leukocytosis, and a very high ferritin. this is a tricky diagnosis due to the broad differential diagnosis and potential range of infections or malignancies that can present with this type of presentation. one of the more specific clues lies in the serum ferritin, which is usually markedly elevated in aosd and often >3,000 ng/ml. the differential diagnosis of a very high ferritin (>1,000 ng/ ml) is limited to hemochromatosis, hemophagocytic syndrome, or aosd. once infection and malignancy have been excluded treatment with high-dose steroids should be initiated in this patient who is sick with this multisystem disease. for mild flares nonsteroidal drugs may be used. a 75-year-old man is referred to evaluate an elevated esr. he has had occipital and bitemporal ha of 3-months duration with associated jaw pain and scalp tenderness. a 1-cm left temporal biopsy is negative for temporal arteritis or vasculitis. on examination he appears cachectic and has diffuse tenderness over the right temporal artery. there is lymphadenopathy and right-sided diplopia with medial rectus weakness. labs reveal normocytic anemia, esr = 88mm/hr. hepatic and renal functions are intact. immunoelectrophoresis is without monoclonality. what tests would you order to confirm the diagnosis? yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 this elderly gentleman has symptoms that are classic for temporal arteritis (ta). headaches and jaw claudication in the setting of a markedly elevated esr should raise suspicion for ta. unfortunately this is a disease of discontinuity and characterized by skip lesions on ta biopsy. ideally a 4-6-cm biopsy should be obtained and a bilateral biopsy will increase the sensitivity, albeit marginally. in this case the 1-cm biopsy length is inadequate. ta responds to high-dose prednisone and untreated can cause optic arteritis resulting in blindness. opthalmoplegia has also been described. myasthenia gravis or a space-occupying lesion would not cause bilateral headaches, jaw claudication, or scalp tenderness. if the clinical suspicion is high and an inadequate biopsy is obtained it should be repeated. another option would be to obtain a color duplex ultrasound, which, in the right hands, can reveal a "halo" sign that is suggestive of active arteritis. a 46-year-old male is admitted with new onset of rectal bleeding after having taken 1,600-mg ibuprofen for an acutely swollen toe. you are asked to examine him by the colorectal surgeon for acute podagra. they are considering a colectomy to arrest the bleeding, which has failed to stop by conventional means. on examination he has a red tender inflamed first toe with exquisite tenderness. lab work reveals mild anemia, mild prerenal kidney dysfunction. uric acid is normal. how would you treat his gout? this patient has acute podagra in the setting of an acute nsaid-induced gastrointestinal bleed. an ia injection of steroid is the optimal management in this patient. colchicine is contraindicated given the renal impairment and potential to further irritate the gi tract. a 22-year-old male presents with recurrent intermittent monoarthritis affecting the toes, knees, and ankle. arthrocentesis reveals intracellular uric acid crystals diagnostic of acute gout. lab work: cr = 0.6 mg/dl, ua = 14 mg/dl, cbc normal. hepatic function is normal. twenty-four hour urine ua is low. what is the most likely diagnosis and cause? yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 the majority of people with gout are congenital underexcretors of ua. the exact mechanism has not been elucidated but it is related to decreased secretion, increased reabsorption, or decreased filtration of ua. overproduction of ua occurs in less than 10% of patients. lesch nyhan syndrome secondary to hypoxanthine guanine phosphoribosyl transferase deficiency (hgprt) would cause an overproduction of ua and increased 24-h urinary uric acid excretion. a 45-year-old female with 10 years of seropositive erosive rheumatoid arthritis presents with new onset of shortness of breath, low-grade fever, and dry cough. her current regimen includes hydroxychloroquine 400 mg/day, prednisone 10 mg/day, sulfasalazine 3 g daily, and infliximab 5 mg/kg. she has never taken methotrexate. she resides in new england, and denies recent travel. examination reveals chronic rheumatoid deformities without active synovitis. pulmonary examination reveals fine diffuse inspiratory crepitations bilaterally. a cxr describes fine perihilar reticular opacification. blood gases revealed hypoxia, and she failed to improve with broad spectrum and empiric macrolide therapy. lab work reveals normocytic anemia without leucocytosis. renal, liver function and cpk are normal. ldh is markedly elevated. peripheral smear is without hemolysis. bronchoscopy reveals negative stains for acid-and alcohol-fast bacilli on three occasions and ppd (tb) skin tests are negative. cmv, mycoplasma , legionella , q-fever, adenovirus, influenza, chlamydia , cytomegalovirus, epstein-barr virus, hepatitis b and c, and hiv titers are negative. what is the most likely diagnosis? this patient who is receiving anti-tnf therapy presents with an acute pulmonary decompensation characterized by dyspnea, hypoxemia, and an elevated ldh level. since she is significantly immunosuppressed, an opportunistic infection is the most likely scenario. rheumatoid lung disease, bronchiolitis obliterans with organizing pneumonia (boop) are also in the differential diagnosis. ra-associated lung disease tends to present more insidiously with pleural involvement and is usually not associated with elevated ldh levels. pcp is caused by a unicellular eukaryote and is a rare cause of infection in immunocompetent individuals. the diagnostic gold standard is a broncheoalveolar lavage (bal) with cytologic confirmation of induced sputum samples. ldh levels are a sensitive but poorly specific indicator of pcp. since this infection is associated with high mortality a high index of suspicion is required. a 44-year-old female presents with recurrent uveitis and scleritis. she has a 3-month history of nasal discharge and shortness of breath. cxr is reported as having cavitatory lesions. nasal mucosa is erythematous and reveals a perforation within the septum. she has no evidence of synovitis, rash, or mononeuritis on examination. microbiologic evaluation, including tb and cocaine use is negative. pfts reveal mild restriction and upper airway obstruction. what is the most likely diagnosis and how would you make this diagnosis? this patient presents with recurrent sinusitis, inflammatory eye disease, and cavitatory lung lesions typical for wg. the definitive diagnosis is made by confirming the presence of noncaseating granulomas on biopsy. serological tests include the presence of antineutrophil cytoplasmic antibodies (c-anca), which have a sensitivity of about 60-88%. antibodies to proteinase 3 (pr-3) are highly sensitive in active wg (90%). other features of wg include subglottic stenosis, pauciimmune glomerulonephritis, mononeuritis multiplex, and arthritis. in this patient other causes of cavitatory lung lesions such as infection need to be excluded prior to treatment. a 33-year-old heterosexual monogamous firefighter is referred for bloody diarrhea and new onset of knee swelling. he is stiff for about 45 min in the morning. there is no history of travel, urethral discharge, or uveitis. on examination he has a warm left knee effusion and mild tenderness in the abdomen. spine forward flexion is slightly limited. a painful erythematous rash is noted on the anterior shins. lab work reveals mild microcytic anemia. esr is 110 mm/h. stool cultures are negative. renal and hepatic function is preserved. what is the most likely diagnosis and how would you confirm it? how would you initially manage his joint pain? this gentleman presents with a syndrome of bloody diarrhea, erythema nodosum, and oligoarthritis. this pattern is most classic for inflammatory bowel disease (ibd). ideally his knee should be drained and fluid sent to confirm a sterile effusion. colonoscopy with biopsy will confirm the diagnosis of ibd. initial treatment of his joint disease can involve local intraarticular injections, analgesic medications, and judicious use of anti-inflammatory medications with close collaboration with the gastroenterologist. axial spondylitis may respond to physical therapy. the response to dmard therapy for peripheral and axial arthritis is often disappointing. monoclonal antibody anti-tnf agents (infliximab and adalimumab), in contrast, work well in this situation. a 67-year-old female with ra is referred for further management. she has multiple comorbidities including chronic renal failure, diabetes, and hypertension. she has pain in the hands, wrists, and feet with 4 h of early morning stiffness. on examination there is polyarthritis of the small joints of the hands with significant joint margin tenderness. prednisone at 15 mg daily and weekly methotrexate (mtx) at 15 mg is commenced. you are called by the er 1 week later where she is being seen for new onset odonophagia and dysphagia. on examination she has severe mucosal ulceration. lab work reveals mild hyperglycemia and stable renal dysfunction. what complication has occurred? how could this have been prevented? this patient with renal failure has developed mucositis from the methotrexate. mucosal toxicity is a well-known complication of mtx and predisposing factors include folate deficiency, renal failure, and hypoalbuminemia. there are also various genetic polymorphisms that may predict toxicity and response to mtx. the dose of mtx should be adjusted in patients with renal failure. this complication may have been prevented by the use of a lower dose and prophylactic daily folic acid. a 68-year-old caucasian female is referred for further management of osteoporosis. she underwent early menopause at 43 and did not receive hormone replacement. a bone density taken 2 years before revealed an axial t score of 0.5 and appendicular t score of −2.6. she was treated with calcium supplements and alendronate 70 mg weekly. despite bisphosphonate therapy she has had several fragility fractures in the past year. a repeat dexa is performed and this confirms a slight decline in bone mass. serum electrolytes including alkaline phosphatase, calcium, celiac antibodies, pth, and 25-vitamin d levels are all normal. this patient has multiple risk factors for osteoporosis including early menopause, sex, race, and prior fracture. assuming that she is compliant then the fact that she is fracturing despite bisphosphonate (bp) therapy indicates that she is a true bp failure. teriperatide has an alternative mechanism of action to bp and stimulates osteoblasts as opposed to inhibiting osteoclasts. osteoporosis experts have developed a consensus opinion, published in the spring of 2004, to help clinicians identify appropriate patients for teriperatide therapy. indications for its use were as follows: (1) history of vertebral fracture, t score of −3.0 or below, or age greater than 69 years, (2) fracture or unexplained bone loss in patients on antiresorptive therapy, and (3) intolerance of oral bisphosphonate therapy. contraindications for teriparitide therapy listed include hypercalcemia, paget's disease, a history of irradiation to the skeleton, sarcoma, or malignancy involving bone. this patient has a classic charcot joint, which is characterized by damage secondary to loss of sensation that occurs due to the patient's underlying diabetes. the features of a charcot joint include fragmentation of bone, progressive destruction, and disorganization. although there are many causes, diabetic neuropathy is the commonest cause in the western world. lisfranc dislocation implies disruption of the joint between the rigid midfoot and more supple weight-bearing forefoot. arthrocentesis frequently yields a hemarthrosis. lisfranc was napolean's surgeon who described a technique to amputate the forefoot in soldiers suffering from frostbite. a 58-year-old female from the dominican republic with seropositive ra of 20-year duration is seen due to fever, dyspnea, and malaise. she commenced anti-tnf therapy 1 month prior to her presentation due to poorly controlled ra. her current medications include methotrexate, folate, celecoxib, and infliximab. her examination shows a low-grade temperature of 100.5°f. she has chronic synovitis of the mcp/pip and wrist joints with bibasilar end inspiratory crepitations on pulmonary examination. serum and urine microbiologic studies are negative. a cxr reveals chronic bibasilar fibrosis and a new apical infiltrate. what is the major clinical concern in this patient? yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 this patient has developed a new apical infiltrate in the setting of anti-tnf therapy. tnf is a pleiotropic molecule important in immune surveillance and host defense. it is also important in granuloma formation and maintenance. tnf-deficient knockout mice develop fatal tb and listeriosis. reactivation of tb is a well-recognized complication of anti-tnf therapy, and patients should be screened with skin testing prior to initiation of therapy. this 46-year-old male presents with axial stiffness, metatarsal inflammation, enthesopathy, and sacroiliitis. this is highly suggestive of a reactive arthritis or as. gout has been effectively excluded by the absence of urate crystals and would not typically present with achilles tendonitis or sacroiliitis. other things to examine for would be digital pitting, psoriatic plaques, stigmata of inflammatory bowel disease, urogenital infection, or uveitis. the elevated uric acid is of no clinical significance and the colchicine should be stopped. reveille a 27-year-old female with sle is referred with new onset pleuritic chest pain. she has a history of arthritis and mucositis, which has been controlled on nsaids and antimalarial agents. she has a history of two second trimester miscarriages. on examination she has sinus tachycardia, rv heave, and a loud p2. diffuse livedo reticularis is noted. lung examination is clear and cxr appears normal apart from slightly oligemic fields. she is mildly hypoxic and is using accessory muscles of respiration. what is the most likely diagnosis? yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 this patient with sle most likely has antiphospholipid syndrome (aps) with a history of recurrent pregnancy loss and livedo reticularis. her examination reveals elevated right-sided pulmonary pressure consistent with right ventricular strain. pericarditis should also be considered although it would be less likely given the physical findings. aps is a disease of recurrent vascular thrombosis and fetal loss associated with antibodies to membrane phospholipids. approximately 40% of patients with sle have anticardiolipin antibodies but only 10% have aps syndrome. lockshin md. update on antiphospholipid syndrome. bull nyu hosp jt dis. 2006;64(1-2):57-59. a 78-year-old female is admitted with malaise, fever to 101°f and unintentional weight loss. she has a 45-year history of seropositive erosive ra controlled on methotrexate and more recently intravenous anti-tnf therapy. she has known interstitial lung disease. on examination she is cachectic, with chronic deformities and low-grade synovitis. her lung examination reveals coarse bibasilar crepitations. she has axillary lymphadenopathy and bipedal edema. lab work reveals a normocytic anemia, mild eosinophilia, and hypoalbuminemia but otherwise intact renal and hepatic function. urinalysis is benign. viral, rickettsial, and microbiologic studies are normal; a ct scan reveals marked hilar lymphadenopathy and chronic fibrotic changes at the lung bases. a tuberculin skin test is negative. this patient with chronic ra presents with fever, lymphadenopathy, eosinophilia, and weight loss in the setting of a negative infectious disease evaluation. the differential diagnosis includes infection, tb, and lymphoma. the latter diagnosis is most likely given the negative microbiologic studies. patients with chronic ra are predisposed to lymphoma, and although not clear, in 2007 this risk might be further amplified by concomitant anti-tnf therapy. patients with the most severe disease activity scores have the greatest risk of developing lymphomas. when using biologic agents the benefits of treatment must be weighed against potential toxicity. a 46-year-old male immigrant is admitted for further evaluation of a pulmonary artery aneurysm noted on an incidental cxr. he has a prior history of uveitis and arthritis. on examination there is hypophyon, erythema nodosum, and oral ulceration. what is the most likely diagnosis? yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 this patient has classic behcet's syndrome (bs), which is an hla-b51-associated disease characterized by recurrent orogenital ulceration, thrombophlebitis, uveitis, and vasculitis. skin lesions include erythema nodosum, abnormal pathergy, and folliculitis. the etiology is unknown but this is a disease with racial preference along the old silk route from the mediterranean to china. pulmonary artery aneurysms are a rare cause of pulmonary hemorrhage and should raise the suspicion of bs. a 67-year-old african american female with dialysis-dependent renal failure is evaluated for recurrent carpal tunnel syndrome. she has had two injections in the past 6 months, which were of temporary benefit. on examination she has atrophy of the thenar eminens and weakness of opponens muscles. phalen's sign is positive and her grip is diminished. what complication has occurred? yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 a 55-year-old female with chronic renal failure is seen for evaluation of lower extremity edema and ankle pain. one month before she had an mri with gadolinium for low back pain. on examination a woody induration is noted over the shins bilaterally. a skin biopsy is performed, which reveals mucin deposition and a proliferation of fibroblasts and elastic fibers. what is the most likely diagnosis? discuss. yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 this patient has crest syndrome and elevated right-sided pulmonary pressures by conventional 2d echocardiogram. since pulmonary hypertension is a major cause of mortality in these patients, further investigations are warranted. her echocardiogram reveals pulmonary hypertension (normal mean pa pressure<25 mmhg) although there is a clear disconnect between her symptoms, examination, and the echo findings. there are differing opinions in this scenario but in an asymptomatic patient she could probably be observed for clinical deterioration or symptoms. a 6-min walk test is also helpful and if abnormal, a right heart catheterization can be considered. this patient had normal pa pressures on right heart catheterization. this case illustrates the limitations of accuracy of echocardiography in obese patients. posterior reversible encephalopathy syndrome (pres) or reversible posterior leukoencephalopathy syndrome (rpls) is an increasingly recognized neurologic disorder with characteristic computed tomographic (ct) and magnetic resonance (mr) imaging findings, and is associated with a multitude of diverse clinical entities. these include acute glomerulonephritis, preeclampsia and eclampsia, systemic lupus erythematosus, thrombotic thrombocytopenic purpura, and hemolytic-uremic syndrome, as well as drug toxicity from agents such as cyclosporine, tacrolimus, cisplatin, and erythropoietin. most, but not all, cases manifest with acute to subacute hypertension, and seizures are also frequent. two pathophysiologic mechanisms for pres have been proposed. one postulates cerebral vasospasm with resulting ischemia within the involved territories, whereas the other posits a breakdown in cerebrovascular autoregulation with ensuing interstitial extravasation of fluid. this case is particularly difficult in that a patient with sle who presents with a seizure and hypertension has to be excluded for active cerebritis or nephritis. the normal lumbar puncture and characteristic mri findings are highly suggestive of pres. treatment involves normalization of bp, removing offending agents such as cytoxan, and prevention of further seizures. a 25-year-old female has had low back pain for 6 months. she has an unremarkable past history apart from one prior episode of uveitis. review of systems is negative for diarrhea, urethral discharge/travel, or constitutional symptoms. her examination reveals a positive faber sign and tenderness over the lower lumbosacral spine and sacroiliac joint. the rest of the joint and skin examination is normal apart from subungual hyperkeratosis and oil spots. what is the most likely diagnosis? yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 infections associated with tumor necrosis factor-alpha antagonists tumor necrosis factor-α is required in the protective immune response against mycobacterium tuberculosis in mice tuberculosis in the cytokine era: what rheumatologists need to know major arterial involvement and review of behcet's disease. ann vasc surg pulmonary vasculitis in behcet disease: a cumulative analysis behçet's syndrome: disease manifestations, management, and advances in treatment the clinical manifestations usually develop after several years of dialysis dependence and include carpal tunnel syndrome, destructive arthropathy, bone cysts, and fractures. risk factors for the development of dra include age, duration of dialysis treatment, use of low-flux dialysis membrane, use of low-purity dialysate, monocyte chemoattractant protein-1 gg genotype, and apolipoprotein e4 allele. surgical management is usually successful but can result in recurrence dialysis-related amyloidosis: late finding or hidden epidemic? semin dial management of carpal tunnel syndrome in renal dialysis patients using an extended carpal tunnel release procedure comparison of doppler echocardiography and right heart catheterization to assess pulmonary hypertension in systemic sclerosis pulmonary hypertension in systemic autoimmune disease a 41-year-old female is referred due to 4 years of recurrent sinusitis. she has failed multiple antibiotic courses and has recently developed left-sided horizontal diplopia.her lab work is consistent with anemia of chronic disease and an elevated esr of 86 mm/h. cultures for bacteria, fungi, and tubercles are negative. a ct scan of the sinuses confirms destructive pansinusitis with a nasopharyngeal mass. serologies are consistent with a +p-anca, −canca, and −pr3/mpo antibody. renal and pulmonary functions are preserved.what is the differential diagnosis and most likely scenario? what treatment is advisable? this 41-year-old patient presents with a 4-year history of recurrent sinusitis in the setting of a positive p-anca, destructive nasopharyngeal mass, and ophthalmoplegia.the differential diagnosis includes infection with a refractory organism, such as mucormycosis or tuberculosis, malignancy, midline granuloma, or vasculitis. infection and malignancy seem less likely given the chronicity and lack of positive cultures.although most patients with wg have antibodies to proteinase-3 and positive c-anca antibodies, a small minority have antibodies to p-anca.this patient's inflammation has extended into the sinuses and cavernous sinus causing cranial neuropathy and ophthalmoplegia.optimal treatment involves oral corticosteroids and oral daily cyclophosphamide. prior to the introduction of cytotoxic drugs this was a disease of very high mortality. a 67-year-old diabetic african american male is referred for evaluation of chronic right ankle pain. there is a distant history of trauma and poorly controlled diabetes. he denies podagra, and serum uric acid is normal. on examination he has fair peripheral circulation, pes planus with mild ankle tenderness at the tibiotalar joint, and glove and stocking neuropathy is present. his radiograph shows diffuse demineralization and lisfranc dislocation of the midtarsus. the joint is tapped and hemarthrosisis noted.what is the most likely diagnosis? who was lisfranc? you are asked to see a 46-year-old alcoholic male to help with the management of presumed gout. he presented with acute bilateral ankle pain and swelling. he has chronic low back stiffness. the admitting physician has performed arthrocentesis of the ankle joint, which confirmed type 2 inflammatory fluid without crystals. lab work reveals intact hematologic and renal function and ua = 8.4 mg/dl.on examination he has bilateral tenderness over the right metatarsal heads, thickening of the achilles tendon with exquisite tenderness, and warm bilateral ankle effusions. radiographs of the spine confirm right sacroiliac fusion. he is treated with colchicine without any improvement.what is the most likely diagnosis? what else would you look for on examination? nephrogenic fibrosing dermopathy/nephrogenic systemic fibrosis (nsf) is an emerging scleromyxedema-like cutaneous disorder of unknown cause that is seen in patients with renal failure; the number of reported cases has grown significantly since its first recognition. virtually all cases of nsf have been associated with the administration of gadolinium-containing contrast media. skin biopsies of affected areas reveal thickened collagen bundles, mucin deposition, and proliferation of fibroblasts and elastic fibers. the etiology is unknown but gadolinium may act as a stimulant to attract circulating fibrocytes to the dermis. ideally gadolinium should be avoided unless absolutely necessary in patients with renal failure. you are asked to see a patient with refractory erythema nodosum. he is a 46-yearold ex-intravenous drug abuser who has had painful raised lesions over his shins for 4 months. he also complains of low-grade fever, arthralgia, and abdominal pain. he has lost 15 lbs in 6 months. on examination temperature is 38.3°c, and there is evidence of clubbing and tender raised nodules over the anterior shins. his cardiac examination reveals a 3/6 ejection systolic murmur at the right sternal border and 2/6 early diastolic murmur. bp = 166/64. pulmonary examination is normal, and abdominal examination reveals tenderness in the ruq. a cxr is normal.what diagnostic test should be performed?yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, humana press, a part of springer science + business media, llc 2009 this patient has endocarditis with valvular insufficiency and probable streptococcal bacteremia. streptococcus is a common cause of erythema nodosum (en). other causes include sarcoidosis, tb, yersinia, fungal infections, inflammatory bowel disease, behcet's disease, and drugs such as sulfonamides. a 29-year-old resident is seen for refractory foot pain of 1-week duration. her past medical history is significant for anorexia nervosa for which she attends monthly counseling classes. her weight is 87 lbs, height 5′6″. on examination she has diffuse tenderness at the midfoot. she denies trauma or swelling.what is the diagnosis?yousaf ali, self assessment questions in rheumatology, doi: 10.1007/ 978-1-59745-497-1, because of anorexia nervosa and low body mass this patient is at a higher risk for osteoporosis and fragility fracture. this radiograph clearly shows two healing metatarsal fractures, which are the cause of the patient's pain. the decreased bone density in patients with anorexia nervosa (an) is due to the many effects on bone metabolism of amenorrhea, reduced levels of insulin-like growth factor-1 (igf-1), high cortisol levels, and weight loss. although bisphosphonates have been used the most effective treatment involves resumption of menses and weight restoration. a 59-year-old diabetic male has pain over the anterior hip and groin. he has recently had angina and has started a vigorous exercise regimen. on examination there is clicking of the hip with flexion but no pain with rotation. distal neurovascular examination is intact. a radiograph of the right hip and pelvis is normal.what is the most likely diagnosis? how would you treat him? the iliopsoas muscle passes anterior to the pelvic brim and hip capsule in a groove between the anterior inferior iliac spine laterally and iliopectineal eminence medially. it acts as one of the hip flexors and is occasionally injured in excessive hip flexion or trauma. patients often have an insidious onset of anterior thigh pain, which often radiates down to the knee and is associated with hip clicking.treatment involves physical therapy to alleviate pain, spasm, and swelling. a 35-year-old markedly obese female is referred for evaluation of scleroderma. she is asymptomatic but has limited sclerodactly and skin thickening of the face, digits. nailfold examination shows dilated capillary loops. lab and urine data are normal. she is diagnosed with crest syndrome on the basis of esophageal dysfunction and raynauds.cardiac examination reveals a normal s2, and pulmonary examination is clear without rales.a baseline 2d echo reveals a pa pressure of 45 mmhg (nl < 25) but pfts and dlco are normal.what is the next appropriate step? a 28-year-old female with sle is diagnosed with class 4 nephritis. she is started on immunosuppressive therapy with pulse cyclophosphamide, prednisone, and furosemide.three months after the initial presentation she is admitted with hypertension and has a witnessed tonic clonic seizure in the er. her bp is 190/115 and she appears post ictal when you examine her. there is no rash, synovitis, or evidence of serositis. an lp is unremarkable without evidence for infection or cerebritis.a brain mri reveals multiple hyperintensity lesions in the occipital lobe.what complication has occurred? cutaneous manifestations of psoriasis include oil spots or "oil droplets" -orangebrown patches seen through the nail plate, nail pitting, onycholysis, and subungual hyperkeratosis. psoriatic nail disease is often associated with psoriatic arthropathy. this patient also has evidence of inflammatory low back pain, uveitis,and sacroiliitis, which are all characteristic of psa. faber's test (flexion, abduction, external rotation) is a test for the sacroiliac joint and hip disease. if the patient has pain in the groin it suggests hip pathology but if the pain is in the sacroiliac area it is more consistent with sacroiliitis. a 67-year-old caucasian female is referred for left forearm pain for 2 months duration. she describes pain that only occurs with activity. her pmh includes newly diagnosed pmr, cad, and spinal stenosis. her current medications include prednisone 5 mg daily, aspirin, and atenolol. on examination she is mildly cushingoid with an absent left radial pulse. there is no peripheral synovitis, and examination of the forearm and elbow joint is unremarkable. resisted extension of the wrist fails to reproduce the pain. there is a faint left subclavian bruit.her laboratory data reveal an elevated esr of 80 mm/h, and normal renal and biochemical parameters. she has a mild normocytic anemia.what is the most likely scenario? what is the next best step to evaluate this? this patient has a recent diagnosis of pmr and now presents with claudication of the left upper extremity in the setting of an absent pulse and markedly elevated inflammatory markers. at this point the diagnosis of exclusion is temporal arteritis (ta) with large vessel involvement. the presence of a subclavian bruit also suggests proximal occlusion. takayasu's arteritis is also a possibility but less likely given the patient's age and ethnicity. atherosclerosis needs to be considered but again should not be associated with this degree of inflammation. large-vessel involvement in giant cell arteritis occurs in over a quarter of patients with this disease. stenosis of the primary and secondary branches of the aorta may cause claudication and tissue gangrene, whereas aortitis may lead to aneurysm formation and dissection, often many years after the initial diagnosis. the important thing here is to treat the inflammation and ensure that no other organs are involved. a temporal artery biopsy is the best next step. occasionally ta can be silent and only becomes apparent when a biopsy is performed. what is the diagnosis? this is a very destructive form of psoriatic arthritis with significant periarticular bone resorption. the erosions can cause a "pencil in cup" deformity where one articular surface is eroded creating a pointed appearance; the articulating bone can be concave, resembling an upside down cup. this patient has severe hip pain.what does the x-ray show and what advice would you give to the orthopaedic surgeon? diffuse involvement of the left hemipelvis is manifested by areas of mixed sclerosis and lucency. there is also involvement of the right hemipelvis near the right sacroiliac joint, secondary hip osteoarthritis, and thickening of the iliopectineal line. antiresorptive treatment should be commenced prior to hip replacement to decrease the hypervascularity and decrease the risk of perioperative bleeding. this patient has postpartum pain.what does the x-ray show? osteitis condensans ilii (oci) is the radiologic appearance of increased sclerosis in the inferior aspect of the body of the iliac bone arising in a triangular configuration from the lateral aspect of the sacroiliac joint (si). it is seen most commonly in multiparous women, but also in some degenerative conditions. it is merely a benign reflection of bone remodeling with response to stress, but with the increased radiologic density it is indicative of sclerosis. the si joints themselves are normal or may feature some degenerative -but not inflammatory or erosive -changes. this condition may sometimes be confused with sacroiliitis, but it can be differentiated by its unilateral nature, lack of erosive or other inflammatory features, both locally and in the spine, and the general absence of clinical symptoms. this patient has refractory wrist pain. schmorl's nodes are defined as herniations of the intervertebral disc through the vertebral end-plate. schmorl's nodes are common, especially with minor degeneration of the aging spine. schmorl's nodes usually cause no symptoms, but reflect that wear and tear of the spine has occurred over time. this radiograph also shows a defect at the anterior body of l1 reflecting protrusion of the intervertebral disk beneath the ring apophysis of the growing vertebral body. this 77-year-old male is asymptomatic. a routine chest radiograph notes an abnormality in the spine. his lab work is normal.what is the most likely diagnosis based on this lateral view? what other film would be helpful? how would you manage him? a pelvic/ sacroiliac view would be helpful to exclude sacroiliitis. as is very unlikely at this age. see q18.no treatment is indicated. describe these x-rays. what is the diagnosis?answer: renal osteodystrophy with rugger jersey spine. note the renal transplant.renal osteodystrophy combines features of secondary hyperparathyroidism, rickets, osteomalacia, and osteoporosis. bone resorption in renal osteodystrophy is quite complex. renal retention of phosphate results in hyperphosphatemia, which reduces serum ionized calcium levels, therefore inducing hyperparathyroidism. the hyperparathyroidism increases bone resorption, which may normalize serum calcium levels by releasing the osseous storage of calcium. the various sites of bone resorption include the subperiosteal region of the phalanges, the phalangeal tufts, proximal femur, proximal tibia, proximal humerus, distal clavicle, and calvarial trabeculae. if parathormone levels are mildly elevated over a longer period of time, its effect on bone tends to be anabolic. these effects include excessive maturation of osteoblasts leading to new bone formation and increased laying down of osteoid, which calcifies under the influence of secondarily elevated serum calcium levels. this patient has classic endplate involvement, which results in the appearance of a "rugger jersey." describe the x-ray. what is the diagnosis? characteristic radiographic findings of gout are well-defined, punched-out erosions with overhanging edges, preservation of the joint space, lack of periarticular osteopenia, asymmetrical involvement, soft tissue nodules, and intraosseous calcifications. key: cord-301635-6fjdphmw authors: rant, melita balas title: sustainable development goals (sdgs), leadership, and sadhguru: self-transformation becoming the aim of leadership development date: 2020-11-30 journal: the international journal of management education doi: 10.1016/j.ijme.2020.100426 sha: doc_id: 301635 cord_uid: 6fjdphmw the context of the sdgs resembles the properties of a complex adaptive system (cas). cas requires a specific form of leadership and leaders capable of creating social movements and via that way inducing large-scale system transformation towards the attainment of sdgs. leaders capable of creating social movements tend to be those who occupy the highest levels of adult development (also referred as orders of consciousness). in this paper, we study the leadership approach towards the attainment of sdgs of leader, humanist and mystic from india jaggi vasudev sadhguru. we have chosen him because he has initiated several social movements that have already created effects specified by sdgs. we study his approach to leadership by applying kegan's (1994) framework of meaning-making and subject-object theory for the 5th order of consciousness. after analyzing sadhguru's approach from that perspective, we discuss how leadership development programs should be re-designed to produce more leaders of sadhguru's type. we contribute to the gap between adult development and leadership development if the aim is to facilitate the vertical development of participants towards the highest order of consciousness which in effect will be more capable of attaining sdgs. many lives for the better and has produced many other positive effects specified by the sdgs. sadhguru is an in-spirited (steiner, 1999 (steiner, / 1893 leader that could be classified as a very evolved person from the perspective of the neo-piagetian constructive school of adult development (cook-greuter, 1999; kegan, 1994) . in this paper we claim that the more evolved the leader on the neo-piagetian developmental framework, the more transformative the leadership style likely is (rooke & torbert, 2005) and the greater the likelihood of inducing the effects specified by the sdgs. in this paper, we explore why leaders that are highly evolved along the neo-piagetian developmental framework induce more transformative effects than the lesser evolved leaders. to understand that, we first discuss the properties of the context created by sdgs. this is the context where the leadership for the sgds should emerge. then we discuss how the sdgs should be viewed from the perspective of leadership effectiveness. here, we adopt the perspective that aspirations to meet the sdgs impose the highest order cognitive demands on the leader (kegan, 1994) , alongside this perspective we explore the relationship between the orders of consciousness, leadership approaches, and leadership effects. then, we carry out an in-depth study of sadhguru's approach to leadership. we have selected the sadhguru because, first, he has demonstrated effectively the kind of leadership that produces the effects specified by the sdgs; second, he tends to discuss and dissect his approach to leadership in great detail; and third, he likes to disseminate his approach to other leaders in the position of power. we analyze his approach to leadership from the perspective of kegan's subject-object theory and meaning-making mechanism for the 5th order of consciousness. in the last section, we explore how leadership development programs should be designed in support of the development of leaders capable of implementing sdgs. this last section is discussed in terms of what should be novel assumptions on which such programs should be designed from. specifically, we also expose how the existing program design assumptions should change to develop leaders capable of meeting sdgs. the paper contributes to the field of leadership development program design in several ways: (1) it studies the properties of the leadership approach of the 5th order of consciousness from the perspective of kegan's subject-object theory; (2) on the case of sadhguru's approach to leadership it illuminates novel properties of the subject-object relationship of the 5th order of consciousness and (3) it discussed how the existing leadership programs designs assumptions should be replaced new assumptions if the aim of such program is the development of leaders for the sdgs. in this paper, we treat sdgs as indicators of the desired leadership effects. leadership effects are the effects that can be attributed to a specific leader's decision and action. this attribution is difficult because the leader's effects tend to be distributed over time, spatially distant, and vary in magnitude. we like to justify this perspective in properties of the complex adaptive systems (cas). as specified by the un, sdgs require coordinated action across socio-economic-natural systems on the regional and country-level, across industrial corporations, governmental bodies, educational institutions, ngos. since all these systems are interconnected and nested in each other, we should treat them as complex adaptive systems (cas) . what are the behavioral properties of the cas? prigogine (1977) , kauffman (1996) and waldrop (1993) demonstrated several properties of cas: (1) the inter-relationship, inter-action, and inter-connectivity of the elements within a system, and also between the system and its environment; (2) distributed controlno single centralized control mechanism governs system behavior; (3) coactive changebehavior emerges co-actively from bottom-up and top-down simultaneously; (4) holismbecause it depends on relationships and feedback among components, the overall system behavior cannot be explained merely as the sum of individual parts; (5) co-evolutionelements in a system can change based on their interactions with one another and with the environment; (6) indetrminismoutcomes are predictable probabilistically. cas behavior also exhibits nonlinear effects like (1) saltatory change (stage-like shifts) -small shifts at tipping points can have a surprisingly profound impact on overall behavior; (2) sensitivity of outcomes on initial conditions; (3) multi-finalitysame initial conditional can have multiple clinical outcomes; (4) equi-finalitydifferent initial conditions can lead to the same outcome; and (5) a focus on adaptive variation and local initiative. to sum up, cas also provides the most inclusive capture of properties of the context in which leadership for the sdgs should emerge. the logical question then is, what is the role of the leader and leadership in the context of the complex adaptive system (cas)? the impact of the leader and leadership on the cas tends to be indirect, established primarily through the organizational (collective) identity, and creation of social movements (schneider, somers 2006) . the role of the leader is to seed and cultivate the collective identity, and to activate social movements that, through multiple pathways lead to the effects that are specified by the sgds. the effects also are determined by the initial conditions, which when it comes to a leader and leadership, are determined by the order of consciousness. two individuals can construct different meanings from an identical event, depending on their respective order of consciousness (scharmer, 2009) . orders of consciousness are best captured by neo-piagetian stages of adult development. they denote a distinct way in which people tend to construct their sense of self and attribute meanings to the events (kegan, 1982 (kegan, , 1994 . so which orders of consciousness would most likely produce sdg-specified leadership effects? the neo-piagetian constructive school of human development studies the properties and patterns in which people tend to construct their sense of self and interpret their experiences. the properties of construction of the sense of self is referred as self-referential system; the properties of interpretations are referred as meaning-making system (kegan, 1994) . the neo-piagetian constructive school of human development also studies how these properties and patterns evolve over the lifespan. more specifically, the neo-piagetian scholars have studied different aspects of the human psyche, including the structure of the ego (hy & loevinger, 1996; loevinger, 1976) , social cognition (selman, 1971 (selman, , 1980 , reflective judgment (king & kitchener, 2004), moral judgment (kohlberg, 1981), -meaning-making systems (kegan, 1982 (kegan, , 1994 , cognitive complexity (commons, trudeau, stein, richards & krause, 1998 ), perspective-taking (cook-greuter, 1999 , leadership action logics (rooke & torbert, 2005; tolbert & associates, 2004) , needs and motivations (maslow, 1967; barret, 2016) , and value memes and beliefs (graves, 1974; beck & cowan, 1994 . regardless of the researched aspect, different neo-piagetian scholars have come up with similar findings, namely, that people tend to have in common not so much the content of their life experiences, but the structures through which they organize these experiences (kegan, 1982 (kegan, , 1994 . these distinct structures are variously referred to as stages, orders, ways of knowing, levels of development, organizing principles, or orders of development (mccauley et al., 2006) . hereafter, we use kegan's term 'order of consciousness.' different scholars have come up with different frameworks for depicting orders of consciousness (loevinger, 1994 (loevinger, , 1976 cook--greuter, 1999; 2013; rooke & torbert, 2005) . in this paper, we adopt the kegan's framework. we find it particularly useful for the study of the highest order of consciousness because it is focused on the subject-object relationship. orders tend to follow the invariant evolutionary sequence, with each successive order transcending an including the previous order (cook-greuter, 2013 : wilber, 2001 . because subsequent orders include all earlier structures as special cases, later orders are more complex (they support more comprehensive understanding) than the earlier ones (realms, 2014) . developmental movement from one order to the next is driven by limitations in the current self-referential system and meaning-making mechanism (kegan, 1982 (kegan, , 1994 . once the higher order has been constructed, the previous order loses its organizing function but remains as a perspective that can be reflected upon (cook-greuter, 2013) . the order influences what the person can notice or can become aware of, and therefore, what one can describe, reflect on, change, and control (kegan, 1982 (kegan, , 1994 (kegan, , 2009 . at the same time, the order also determines what is still left unseen, hidden to conscious awareness, thus making a person controlled by it. this distinction between what the person is aware of and what is left hidden is known as the subject-object relationship. all that is in conscious awareness represents the subject; all that is hidden to conscious awareness constructs the object. the order of consciousness seems to be the core predictor of the leadership approach and leadership effects (mccauley et al., 2006; scharmer, 2009; rooke & torbert, 2005) . kuhnert and lewis (1987) proposed that only the leaders operating from at least kegan's 4th order of consciousness (referred also as a self-authoring mind) are capable of transformative leadership approach that drives larger-scale change in the socio-economic system. leaders at the previous orders of consciousness (i.e., kegan's socialized mind and imperial mind) are not capable of adopting transformational leadership due to the limitations of their self-referential system and meaning-making structures. conversely, leaders operating from the highest, 5th order of consciousness (i.e., kegan's self-transformational mind) are even more capable of driving large-scale socio-economic system changes due to their superior self-referential system and meaning-making structures (however, the relationship between 5th order and leadership approach was not researched by kuhnert and lewis but later by rooke & torbert, 2005 research) . the kuhnert and lewis (1987) paper initiated a stream of research on the relationship between the orders of consciousness, leadership approach, and leadership effectiveness (lucius & kuhnert, 1999; harris & kuhnert, 2008; anderson, 2006 anderson, , 2016 . the majority of research linking orders of consciousness with leadership falls in the domain of the integral approach to leadership. research in this domain is mostly published by the integral leadership review (fein, 2018; volckman, 2005 volckman, , 2012 , however this research is still very scarce. the integral approach to leadership is founded on wilber's all quadrants, all levels (aqal) model (walsh, & wilber, 2010; wilber, 2001) . his model links leader orders of consciousness with leadership behavior, collective identity and organizational change. the greatest research gap in this research domain lies in the highest, 5th order of consciousness. a meta-review of distributions of people across different orders of consciousness showed that less than 1% of leaders operate from the highest order (kegan, 1994) . this is the main reason for the scarcity of research of the highest order of consciousness. in the book, in over our heads, kegan (1994) illuminates the properties of the subject-object relationship for leaders that occupy the highest, 5th order of consciousness (self-transformational mind). for the 5th order, the definition of the self (who i am) is incomplete, always forming and re-forming itself. the leader is capable of observing, reflecting, and changing own self-definitions and identifications. the object of observation and reflection for the person operating from the highest, 5th order of consciousness is own self-definitions and identifications with the assumptions and beliefs. previous orders are not capable of that reflection. in kegan terms, the object of observation and reflection becomes "self-as-form". "self-as-form" was hidden so 4th order of consciousness, it was left unconsciousness; but for the 5th order, it moves from the unconscious to consciousness. kegan (1994: 321) further suggests that "refusing to see oneself or other as a single system or form, regarding the premise of completeness as tempting pretense, constructing the process of interacting as prior to the existence of the form or system, facing protracted conflict as likely sign of one's own identification with false assumptions of wholeness, distinctiveness, completeness, or priorityall these ways of constructing reality require that the epistemological organization of system, form, theory be relativized, moved from subject in one's knowing to object in one's knowing. they all require "trans-systemic", "multi-form", or "cross-theoretical" epistemological organization. in other words, they all require 5th order of consciousness". what is left subject for the 5th order of consciousness, thus unseen and hidden to conscious awareness, are the relationships a person holds with other people and nature (kegan, 1994) . cook-greuter (1999) researched the perspective-taking of construct-aware adults, which correspond to kegan's 5th order of consciousness. construct-aware adults are capable of '5th person perspective-taking.' the core capacities related to the 5th person perspective-taking are: "the linguistic process of splitting into polar opposites (dualism) and the attending value judgments can become conscious as well. good and evil, life and death, beauty and ugliness may now appear as two sides of the same coin, as mutually necessitating and defining each other." through reflective observation, "ego becomes transparent to itself"; furthermore, "turning inward and observing one's own mental processes can also lead to the spontaneous discovery of a direct mode of experiencing in which knower and known momentarily merge, and the personal self-sense disappears …" last but not least, they can easily access "intuition, bodily states, feelings, dreams, archetypal, and other transpersonal material states … experience moments of freedom from the ego's constant efforts at control and self-affirmation" (cook-greuter, 1999: 235) . using kegan's subject-object relationship as a framework for the study of highest order leaders, we now turn to the in-depth case study of indian mystic, leader and humanitarian jaggi vasudev sadhguru. 2 we have selected sadhguru because he is a successful leader from the perspective of meeting the sdgs. here are brief descriptions of a few sadhguru's projects that successfully target sdgs 3 : 1. tree planting project: in 2012 sadhguru has launched a large scale environmental project in southern india. their rivers were going dry and groundwater was sinking very rapidly. sadhguru set a goal of planting 114 mio trees in tamil nadu. he approached the goal in a specific way. he addressed 1000 people and made them sit under the trees. while sitting he set up a yogic process, through which he led them to experience in a profound sense how they are not separated from the trees. he did that through a simple yet powerful breathing exercise, telling them that "what they are breathing, the trees are inhaling, what the trees are exhaling, they are breathing in … so bringing this experience into people that what you think as myself is not within the boundaries of your physical nature; it goes well beyond that … once they realized that, there was no stopping for planting threes by them … if this (sense of unity) becomes a living reality, they can fulfil these goals that un has." 4 sadhguru also insisted that trees being planted on small plots of land, less than half an acre; half of the trees are fruit trees and half of them can be used for firewood so that people who live on these lands can benefit from them and thus they are motivated to take care of them. by this simple project, sadhguru initiated a movement of planting trees across india. we claim that this movement directly contributes to sdg #1 and sdg#15. 2. rally for rivers is the second movement launched by sadhguru in september 2017. in 30-day time he gathered 162 mio supporters for rally for river initiative. this great support was coming from ordinary people. it caused an activation of the government of india to start doing "right" action to preserve rivers, fertile land, and reduce the poverty among farmers who lived from those land. sadhguru and the movement have been involved in the redefining of the government policy. one of the first big projects has been done in vavatmal district, which was known as the suicide capital of india (with 4500 farmers' suicides per year). the suicides were related to the disappearing vagari river and increasing non-fertile land, huge debts, and farmers' inability to repay. in the effects of the rally for rivers movement 54 km of the vagari river, which covers 285 km2 of the river basin, got a governmental sanctioned project. farmers received money, also the phone number to call up in times of distress (to provide them with emotional support to prevent suicides) while at the same time changing the landscape by bringing about the horticulture and agroforestry in the region. these actions in effect will greatly augment the farmer's income fast and, in 10-year time, also the vagari river. this project merged an economy and ecology. merges of the ecology with an economy became a flagship for the rally for rivers project. it got also the support of the united nations, which in consequence launched a decade of water action 2018-2028. we claim that this movement directly contributes to sdg#1, sdg#2, sdg#3, and sdg#6. 3. truth and youth: "youth and truth" is the third movement created by sadhguru aimed to empower the youth in india with the required clarity and perspective and to enable them to realize their full potential. the movement was brought to life on the back of a month-long series of college events across india covering a wide range of educational institutions such as iim-a, iit bombay, jnu, nalsar university of law, and others. mass media and digital amplification accompanied these on-ground student events. a digital platform was created which became a repository of both questions from the youth and sadhguru's answers. also, there was a series of informal events in youth-oriented locations. all these events were interactive, candid sessions between sadhguru and students, where students could seek clarity on any topics they chose, be it a career, parents, addiction, stress, relationships, or sexualitynothing was off limits! youth and truth is then turned into a global movement to inspire and empower youth around the globe. we claim that this movement directly contributes to sdg#3 and sdg#4. sadhguru also teaches other leaders to follow his example. for that purpose, he has designed a unique approach to leadership. this approach is analysed by an in-depth case study of sadhguru's speeches to the business audiences in the next section. 2 sadhguru was named in the top 50 most influential indian leaders by india magazine. he has been a delegate to the united nations millennium world peace summit, a member of the world council of religious and spiritual leaders and alliance for new humanity, a special invitee to the australian leadership retreat, the tallberg forum, the indian economic summit 2005-2008, as well as a regular speaker at the world economic forum in davos, ypo, wpo, tiecon, india today conclave, and many more. he is a regular guest at leading educational institutions, including oxford, the london business school, imd, stanford, harvard, yale, wharton, and mit, where he prefers to address issues as diverse as socioeconomic development, leadership, and spirituality. the core platform for these many initiatives is the isha foundation. the isha foundation is, in essence, an organization that uses yogic sciences to deliver the programs that create physical, mental, and emotional well-being (also including special programs for executives). programs have been attended by more than 5 million people around the world. the isha foundation alone is a huge management challenge. the organization is operated by a network of 2 million people (volunteers) worldwide. 3 yoga means to join, to unite, symbolizing the union of body and consciousness. yoga balances body and soul, physical health, and mental wellbeing; it promotes harmony between people and between ourselves and the natural world. recognizing its universal appeal the un general assembly proclaimed the 21st of june as an international day of yoga. un broadcast from june 20, 2020, where the united nations organized a special event on 'conversation with yoga masters -yoga for the achievement of the sustainable development goals (sdgs).', the keynote speaker has been sadhguru. 4 a case study of sadhguru applies a grounded theory approach (corbin & strauss, 1990 . we have gathered secondary sources composed of spoken material, written articles, and published books. audio material was mainly accessed from youtube (videos, transcripts, speeches, thinking) and the sadhguru's isha foundation page. we have focused on available audio material from, 2015 to 2018, though the same material is also slightly older and some newer. we have limited the study with a timeframe since new sadhguru's talks appear daily on youtube and social platforms in great numbers. due to this reason, we have also limited the selection of published talks and focused mostly on those presented to the executive audiences at business schools, conferences, business and economic retreats, and economic forums (i.e., at the world economic forum, united nations, etc.). the chosen audio material totalled to 76 h. all material was listened to comprehensively first. during listening, we took notes to capture the core ideas and messages. we spotted the replication of similar ideas and concepts across the material, and that which captured the replicated ideas and concepts were transcribed. written transcripts amounted to approximately 100,000 words. the transcribed pages were reread by two decoders. the decoders composed their list of codes, concepts, and categories, and looked for the most representative quotes illustrating identified concepts. having the quotes along with the categories was a significant aid in axial coding and the disaggregation of core themes and messages. the core themes unpacked through this process were: (yogic) spiritual process, self-transformation, accumulation, and expansion, identity and personality, inclusiveness, physical and non-physical realm, the sensory body, exuberance, humanity, morality, ambition, and vision. two major observations sprang out of the decoding process. first, in his talks, sadhguru tends to refer to shankaran pillai's stories to encapsulate the core messages. mythical stories are a subtle, yet powerful form of influence of the leader on the followers (parks, 2005) . furthermore, mythical stories tend to "shapes and sustain our emotional attitudes, provides us with life purpose, energizes our everyday acts. it gives life meaning and momentum." (houston, 2009, p. 129) . second, sadhguru (2016) tends to derive lessons and messages out of his life experiences and not through the ascetic study of scriptures. the name sadhguru implies an uneducated guru. he has lived a rich life filled with different types of experiences (resisting over-compliance and schooling, living in a jungle, exploring the world on a bike, building the sacred temple dhyanalinga, etc.). he places yoga and spirituality at the centerpoint of his life experiences, and his leadership action. he defines spirituality as "the ability to look without a motive … " (sadhguru, 2016:15) . the merger between spirituality and leadership is the property of leaders that operate from the highest stage of adult development (tolbert, rooke, 2005) . the core theme sadhguru likes to address is the human tendency of "wanting more." "wanting more" is universally expressed in all humans, but this "wanting more" can be expressed in two forms, "wanting more in a material realm" vs. "wanting more in a nonmaterial realm". in "wanting more in a non-material realm," the creative power of humans lie (sadhguru, 2016) . "wanting more in a non-material realm," should be a driving force behind the leadership actions (and is also the driving force behind his leadership action). sadhguru frequently discusses the properties of "wanting more," in executive audiences. "wanting more is natural to human beings. whoever you are, you want to be something more than you are right now. if you know only money, you are thinking of more money, if you know wealth, you want more wealth; and if you know knowledge, you want more knowledge. whatever is your currency, you want more of that currency … if you see this, you know that you are looking for an infinite expansion. . . . so, if you really look at it, what they (human beings) are looking for is not more, they are looking for all … if you … expand in a limitless way, trying to do it physically is a foolish thing. your desire is fantastic … the method is hopeless … this can only happen if you transcend the limitations of physicality. this is where yoga comes in. yoga means you learn to erase the boundaries of your physicality." 5 the problem is that this evolutionary force of "wanting more" is hidden to the conscious awareness of leaders. if it remains hidden, it operates below the level of conscious awareness; then it gets expressed as an unconscious need to accumulate more of personal possessions, power, status, and career progress. sadhguru does not only discuss only the "wanting more" of material goods and wealth, but also the accumulation of beliefs, past successes, and other experiences around which the sense of self is fixated. this accumulation creates the boundaries of the identity (sense of self). i am what i have accumulated. identification is with the material goods, wealth, past successes, and other sorts of experiences. sadhguru is emphasizing that these accumulations should not define who the person is in a real sense. "what we have accumulated and who we are should remain separate. who i am should not be influenced by what i have accumulated, whether they are material things, information, beliefs, and impressions." 6 when a person over-identifies with either material possessions and/or past experiences (situated in memory), his/her identity is the constraint. the constraint identity of a leader is particularly problematic because it tends to be expressed as the need for career success, hierarchical power, and social power etc. this is the source of over-ambition. the over-ambitions lead to stress, strain, impulsive thoughts, and improper action, which is a signal that the person does not manage the self; in consequence, such a leader is not capable of managing others towards sdgs. in such a state, any success from doing business is accidental, not controlled. "if you want to manage a thousand people, essentially you are managing a thousand minds. if you want to manage a thousand minds, (and) if you are not even able to manage your own mind, it is going to be accidental management." 7 accidental management is expressed as competition and forcefulness in everyday business life. "if you forcefully take something, you will never expand with a full capacity." 8 to propose a solution to this problem, sadhguru discusses the properties of unconstraint, boundless identity. for sadhguru, the "limited identity and its underlying tendency of wanting more in a physical realm" should be recognized, observed, and reflected on. "the more one develops his personality,. . . the more and more you identify yourself with certain limited qualities in life. . . . because you have sort of concretized yourself with your likes and dislikes, opinions, ideas, philosophies, whatever … the spiritual process means that you are trying to dissolve all that you have created … when you say i am turning spiritual, you are turning inward, longing to taste, experience, and establish yourself in another dimension of life … as a person becomes spiritual that means he becomes more malleable …. spirituality means you are de-concretizing it (personality) so that it is malleable. you still play around with the personality, but it is not you." 9 to become capable of practicing leadership that would create effects specified by the sdgs, leaders would need to master this spirituality that allow for constant reshaping of their sense of self, identity, personality. mastering spirituality for sadhguru means that one is capable of expanding own sensory body. here sadhguru emphasizes the difference between the sensory body and physical body. the expanded sensory body is established by putting oneself into a state of exuberance. "your boundaries of sensation are not fixed … if you feel very exuberant, the boundaries of sensation got expanded. the sensory body has an existence of its own … (different from the) physical body … " 10 operating from the expanded sensory body the identity of a person becomes not only more malleable but also more inclusive. "if you consciously crack up your energy to a certain level of exuberance … your sensory body becomes large … and you can feel others within your sensory body as part of yourself … so, if you are joyful, your sensory body will be all over the placethere would be a deep sense of inclusiveness. once your experience of life is inclusive, without being elected, you are the leader … when you are truly inclusive, you will naturally have an insight about everything and the right kind of people naturally gather around you." 11 the next critical insight related to leadership is the idea that "all humans want the same, which is the experience of inner wellbeing." this should be recognized when the challenge is leading others towards collective good. "the fundamental business of any kind of leadership is human well-being. everybody's business is human well-being. it is only the scale and scope which is different from person to person. for some, human well-being means only my well-being, and they don't care what happens to somebody. for another, a person's human well-being means him and his family. for another person, human well-being means him and his community. for another person, human well-being means him and his country. for another person, it is the whole world. only in scale can human beings be different, otherwise every human aspiration is human well-being … so, if you scale is larger than you individual well-being, you are a leader. …" 12 when insight into human wellbeing comes into a person's conscious experience, which happens when a person operates from the expanded sensory body and malleable, inclusiveness identity, the ideas for moral actions can arise. moral action for sadhguru does not comply with the generic notion of morality. "morality has become an important thing in society because people have forsaken their humanity. if your humanity was alive and active, you would not need morality." 13 humanity means being sensitive to others by using an enlarged sensory body for making leadership decisions and actions. "so, what is the most sensible thing to do (is) what brings wellbeing to you and everybody around? this is what one needs to look at constantly." 14 at the most extreme level, the sensory body (the sense of self) expands so much that all limits to the self completely dissolve, and the person merges with all the existence. such experience, which is labelled differently by different wisdom traditions (wilber, 2007) , happens frequently to sadhguru. "in my experience, i do not see myself and somebody else. i just see myself. so this is not even a devotion. this is not even loving. this is just inclusiveness and this is not my idea. this is not my philosophy. this is the way the world is. if you just do not constipate your consciousness by being identified with limited things like your body, your mind, your own culture, your own religion, your own family, your own whatever -if you do not constipate your mind with those kinds of limitations, the existence is all-inclusive." 15 for sadhguru, the stronger is the experience of inclusiveness, the greater is the capability to lead change towards sdgs. in the state of the merger of a sensory body with all existence and sense of ultimate inclusiveness, one gets in touch with the bodhi, the ultimate intelligence that organizes all life into a form, then the life of a leader attains certain magical qualities. reflecting on such experience, sadhguru infers that here lies the real capability of truly transformational leadership on a larger social-natural system scale. "as i began consciously touching that intelligence, which is the source of creation, seemingly inexplicable events started occurring to me. things that i touched were transformed in some way or another … this ability to transform any external and internal reality quite dramatically has continued within and around me to this very day." (sadhguru, 2916: 20) . sadhguru also emphasizes that he is being no different than any other human being. all humans carry the same power. "in every human body, there is an intelligence, a competence, which is capable of transforming a piece of bread, egg, banana into a human body … this is a hidden intelligence, competence. if only you would find access to this intelligence. even if that would be a drop of this intelligence, you would live magically." 16 sadhguru's approach to leadership corresponds to but also advances kegan's notion of the leadership of the 5th order of consciousness (also referred as self-transforming mind). first, self-transformative leaders, who operate from kegan's 5th order of consciousness, tend to identify the self with the process of form creation; object becomes "self-as-form", subject remains the relationships that "self-as-form" forms with others. kegan's self-transformative leaders tend to see self-as-form being incomplete. also sadhguru's core idea is that personality is malleable, non-fixed, changeable, and incomplete, but for sadhguru all relationships with which one identifies with becoming a part of the objective self on which one can reflect upon. thus, here sadhguru extends kegan in a sense that the relationships with which one identifies with are not anymore the subject (unobservable to the self as in kegan's notion of the 5th order of consciousness) but instead become an object of observation (can be reflected upon). in the extreme, relationships with all existence become a part of the self and an object of inner observation. second, kegan studies human relations in the material realm, but sadhguru draws attention to non-material plane of existence. this can be entered through the expanded sensory body and complete dissolution of personality, identity. the object of observation becomes all material realm where kegan's self-as-form and relationships get constructed. the object in sadhguru's become "self-as-unity with many forms of the self". for sadhguru, the measure of unity with many forms can be of different scales (family, organization, nation, planet). if the object is the "self-as-unity" with a group, the leader forms the inclusive identity in this group; the group members then naturally tend to assign idiosyncratic credit (ic) to a person that holds loyalty to the group norms and aspires for the well-being of the group (hollander, 1978 (hollander, , 1992 (hollander, , 2012 . if the sense-of-unity is with a political party, the leader that forms the inclusive identity around the political party gets selected by voters whose wellbeing tries to improve. according to sadhguru, the greater the measure of unity, the better. when it comes to the sdgs, the measure of unity should become the whole planet, whole existence. in sadhguru's conception, the whole sensory body of the person should encompass all life on the planet as part of the self for the attainment of sdgs. third, kegan (1994) states that leadership of self-transforming adults adopts "an order of consciousness that is able to subordinate or relativize systemic knowing" (kegan, 1994, p. 316) , and "move systemic knowing from subject to object" (kegan, 1994, p. 317) . sadhguru instead talks about getting into touch with the ultimate intelligence that magically organizes all life. this intelligence is the ultimate way of knowing in sadhguru's sense. however, also in sadhguru's sense this intelligence remains the subject, unseen, hidden, unobservable directly to the self. sadhguru holds a sense of unity with all existence, and frequently gets in touch with ultimate intelligence as way of knowing. when in touch with this intelligence, a leader can attain in-spirited ideas to conduct moral leadership action (steiner, 1999/1893). sadhguru's approach to leadership confirms his transformative (almost magical) impact on diverse groups of people that got activated to form the social movements, i.e., planting trees, rally for rivers, truth, and youth. here, the other case studies of leadership of nelson mandela, mahatma gandhi, and martin luther king showcase the transformative powers of inspirited leaders other than sadhguru (morselli & passini, 2010) . in an organization science narrative, sadhguru's inclusive identity could be replaced by the concept of collective awareness as the key to the revitalization and re-enlightenment of the post-modern society (hoffman, jennings, 2018) . here we inquire into the change of assumptions on which leadership development programs that aim to develop leaders for the sdgs should be designed on. first, we outline the change in the assumption space on which leadership development programs are to be designed; then we outline the core design principles and goals of leadership development programs. some of the changes in the assumptions are implied directly from the analysis of sadhguru; while others are implied indirectly by reflecting upon how sadhguru has been developed into a leader for the sdgs. we ask how the programs should be designed if we want to systemically produce more of the "sadhguru" type of leaders. old assumption. skills and competence that need to be developed can be predicted new assumption. in transformational environments the only skills required, that could be also be predicted, are the artistry of self and social transformation leadership development programs should acknowledge that the only predictability of the future is the "unpredictability" that stems from the restructuring of major social arrangements in the global environment, including: the social arena (i.e., the greying of the workplace, generation y/z, empowered workforce, self-led, leaderless, rise of soft-skilled workers, skill specialisation, the need for a strong culture, the psychology of work), the technological (i.e., bio-machinery, smarter robots, the internet of things, information overload and big data, disruptive technology, distributed manufacturing), the economic (i.e., vuca, changing business lifecycles, the social impact of business, the rise of collaboration, prosumers, changes in the reward structure, the need for anticipation, entrepreneurs and entrepreneurs), the environmental (i.e., environmental movement, reclaiming the environment, environmental crisis), and the political (i.e., corporate social responsibility, the post-capitalist society, value pluralism) (suderman, foster, 2015) . in the face of such a transformation of the leadership landscape, there is a need to educate future leaders around novelty, innovation, intuition, and sense-making (burn, houston, 2015) . as such, burn and houston suggests that leaders need to function as social artists and that leadership programs should be designed around four domains: (1) sensory-motor, (2) psychological-historic, (3) mythical-symbolic, and (4) integrative unitive. in the first domain, leaders need to acquire the capacity for "somatic knowing" to discern what feels right; in the second domain one learns to reflect upon the self-schema (the story one constructs around the self and where one tends to suppress and silence the self); and liberate oneself from unconscious, habitual ways of reacting. in the third domain, leaders learn how to use the mythical and symbolic language through which "leaders articulate and interpret the cultural narratives in ways that inspire people to act, which directly impact organizational and community dynamics, on both local and global levels" (burn, houston, 2015, p. 232) . in the fourth domain, one needs to learn the properties of the complexity of leadership, which is based on understanding the organizations and social collectives as the self-organizing systems. new assumption. vertical adult development and transformational learning leadership development is currently not sufficiently designed around the notion that leader development unfolds in the context of adult development; thus not sufficiently acknowledging the regularities of adult development (day et al., 2014; mccauley et al., 2006) ; and dismissing the notion that the stage on which a person is operating from substantially defines their self-referential system and meaning-making capacities (kegan, 1982 (kegan, , 1994 . personality (vincent, 2014) and leadership styles are largely dependent upon the order of consciousness (mccauley et al., 2006) . to make this transition to vertical development, we need to understand the difference between informational and transformational learning. currently, leadership programs are designed around informational learning, which is aimed "at increasing our fund of knowledge, at increasing our repertoire of skills, at extending already established cognitive structures … " kegan, 2009, p. 42) . in addition to informational learning, leadership development programs should also be designed around the principles of transformational learning. leadership programs should aim to develop two cognitive capacities: (1) the capacity to shape "a coherent meaning out of the raw material of our outer and inner experiencing … our perceiving is simultaneously an act of conceiving, of interpreting" (kegan, 2009, p. 44) ; underneath lies, informational learning; and (2) capacity to reform the meaning-making; underneath lies transformational learning. reforming the meaning-making is a meta-process that unfolds in the inner landscape. old assumption. concept-based, knowledge transference program orientation new assumption. experience-based, action-oriented program orientation third, both academics and management practitioners criticize management and leadership for their lack of relevance to practitioners, since they are not designed around students' real-life business challenges and problems. thus, to gain relevance, leadership development programs should be organized around the principles of design thinking, with the minimum level aim to broaden the perspective-taking on problem definition and an action-oriented approach to solution searching among participants lacking relevant work experience (dunne, martin, 2006) . however, for leaders with sufficient work experience, the program design should acknowledge that "everything that every effective manager does is sandwiched between action on the ground and reflection in the abstract. every manager has to find a way to combine these two mindsetsto function at the point where reflective thinking meets practical doing" (gosling & mintzberg, 2003, p. 56) , and that the principles he/she practices of managing to revolve around the five perspectives: (1) managing the self by reflective mindset; (2) managing organizations by the analytic mindset; (3) managing context by the worldly mindset; (4) managing relationships by the collaborative mindset; and (5) managing change by the action mind-set. as a result, gosling and mintzberg (2003) suggest that leadership development programs be structured into five modules, whereby each of the modules aims to develop one aspect of the mind-set. furthermore, leadership development programs should serve as a holding environment for identity restructuring (snook et al., 2010) , thus incorporating into leadership design such potentially dis-equilibrating experiences that are personality salient, interpersonal in nature, and emotionally engaging (manners & durkin, 2000) . at the same time, sufficient support in terms of coaching during the process of transition from lower to higher orders of consciousness must be put in the program design (kegan & lahey, 2009 ). new assumption. development of character and self-aware through cloninger (2004) redefined the personality as the dynamic organization within the individual of the psychobiological systems through which the person both shapes and adapts uniquely to an ever-changing internal and external environment (cloninger, 2004) . personality is a three-layer construct of: (1) temperament (cloninger, 1986) , which is heritable and stable; deterministic, where pre-logic, is subjectively linked with basic emotions and is not rational or self-aware; (2) character (cloninger et al., 1994) , which is an outcome of higher cognitive processes that modulate conflicts, are contingently logical, hierarchical, algorithmic (predictable), subjectively linked with secondary emotions, rational, not self-aware; and (3) self-aware though (cloninger, 2004) , which quantifies levels of coherence and well-being experienced in one's life, which is intuitive, holographic (parts elicit wholes), creative (original, not algorithmic), rational, and self-aware. the aim of a leadership development program should be the development of character and self-awareness though, thus the measurement of the program effectiveness could also be accomplished by measuring character development with the application of the cloninger's tci inventory (cloninger et al., 1994) , and a 360-competency assessment as an indicator of progress (anderson, 2006 (anderson, , 2016 . old assumption. authority-based, leader-centric view on leader and leadership new assumption. trust-based, distributed approach view on leader and leadership heifetz (2015) proposes the need to distinguish leadership from both formal and informal authority to clarify the relationship between leadership fuelled by a formal authority relative to leadership fuelled by an informal authority. heifetz proposes that leadership from an authoritative position is constrained, and participants need to better understand these constraints to overcome them. specifically, authority is defined as a "relationship in which one party entrusts power to another in exchange for service. the power entrusted for service" (heifetz, 2015: xi) . both formal and informal leadership roles are made by authorization. better understanding how authorization empowers leadership is also required to "investigate the virtue and value of authority structures in our lives, and at the same time the ways authorities became untrustworthy" (heifetz, 2015: xi) . removing the trust of the follower towards authority requires that leadership development programs aim to: (1) prepare and train authorities to be trustworthy; and at the same time (2) address the fact that followers can be also distrustful towards authority. the critical development challenge of advanced leadership development programs should be to develop skills to repair the historic distrust of their people by learning how to acknowledge historic injustice, collective pain, and trauma, and "how to be on the receiving end of historic anger with grace" (heifetz, 2015: xii) . this is most likely the toughest developmental goal of all. new assumption. leadership development programs with a blended design or in an online environment leadership development programs have been designed on a premise to create a set of challenging experiences that put participants out of their comfort zone (chaiklin, 2003) . in this zone, a program should provide support, holding the environment for the participants to acquire new insights, lessons, and to transition to new identities (ibarra et al., 2010; petriglieri & petriglieri, 2010) . the covid-19 pandemic required swift transition of all leadership development programs in the online environment in a hurry (dill et al., 2020) . that was a natural challenge for both, learners, but also educators; thus no need for creating superficial challenges. the reflection on that adaptation alone would provide a valuable learning opportunity for all. the online environment carries specific advantages and disadvantages for leadership development (jenkins, 2016) . if leadership aims to develop leaders for the sdgs, covid-19 induced online leadership programs' additional learning advantage. they make a real-time comparison between leaders more acceptable. for instance, comparing leadership approached across different types of political and other leaders on, how they respond to the same threat, (the covid-19) provides valuable insight into how leaders who operate from different orders of consciousness tend to interpret and respond to the same threat. if the programs last longer, the effects of their actions can be also monitored and discussed over time, and discussed from the perspective of the sdgs. we conclude that the highest order leaders are more likely to produce the effects specified by the sdgs. they tend to operate from the expanded sensory body (feeling of exuberance) and sense of inclusive identity (being one with many). in such a state, they tend to perceive leadership challenges slightly differently than leaders that operate from lower orders of consciousness. their perceptions of leadership challenges are much more concerned with the wellbeing for many, including nature, the options considered to resolve such challenges are judged through the criteria of "wellbeing for many". they tend to initiate some social movements and by some strange causality, they affect specified by sdgs. sadhguru likes to imply that normal causality does not apply to the kind of leadership he is propagating. "there are a lot of textbook scientists who will immediately say "oh, he is spreading pseudoscience." well, their idea of science is rudimentary. real scientists will never say such things because they know what they have explored is a tiny speck; what is unexplored is limitless." 17 however, scientific support to sadhguru's ideas can be found in the large repository of the heart math institute. 18 their findings confirm that consciousness, spirituality, and high-quality leadership decision-making and impact are closely related categories. the aspiration of leadership programs to produce sadhguru's type of leaders require change in the assumption on which these programs are designed. the movement should be: • from "skills and competence that need to be developed can be predicted" to "in transformational environments the only skills required, that could be also be predicted, are the artistry of self and social transformation"; • from "horizontal adult development and informational learning" to "vertical adult development and transformational learning"; • from "concept-based, knowledge transference program orientation" to "experience-based, action-oriented program orientation"; • from "development of critical thinking and informed judgment" to "development of character and self-aware through"; • from "authority-based, leader-centric view on leader and leadership" to "trust-based, distributed approach view on leader and leadership"; • from "leadership development programs at venues" to "leadership development programs with a blended design or in an online environment". these are huge changes in the leadership program design, so implementing at least some of them would create programs that would 17 with sadhguru in challenging times -04 apr 6:00 p.m. ist. accessed on: www.youtube.com/watch?v=xlxlkl2ajc0. 18 hearth math organization. https://www.heartmath.org/. more likely produce leaders capable of attaining sdgs. melita balas rant: funding acquisition, hereby 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a guide to realizing your true potential measuring ego development identity-based leader development handbook of leadership theory and practice teaching leadership online: an exploratory study of instructional and assessment strategy use at home in the universe: the search for the laws of self-organization and complexity in over our heads: the mental demands of modern life what "form" transforms? a constructive-developmental approach to transformative learning immunity to change: how to overcome it and unlock potential in yourself and your organization transactional and transformational leadership: a constructive/developmental analysis ego development: concepts and theories adult development and transformational leader processes involved in adult ego development: a conceptual framework the use of constructive-developmental theory to advance the understanding of leadership avoiding crimes of obedience: a comparative study of the autobiographies of mk gandhi, nelson mandela, and martin luther king leadership can be taught: a bold approach for a complex world identity workspaces: the case of business schools self-organization in non-equilibrium systems seven transformations of leadership organizations as complex adaptive systems: implications of complexity theory for leadership research taking another's perspective: role-taking development in early childhood the growth of interpersonal understanding action inquiry. the secret of timely and transforming action evolving consciousness in leaders: promoting late-stage conventional and postconventional development (unpublished doctoral dissertation) assessing executive leadership: an integral approach integral leadership and diversity-definitions, distinctions and implications complexity: the emerging science at the edge of order and chaos integral spirituality: a startling new role for religion in the modern and postmodern world key: cord-317912-v2wovcqd authors: akmatov, manas k.; gatzemeier, anja; schughart, klaus; pessler, frank title: equivalence of selfand staff-collected nasal swabs for the detection of viral respiratory pathogens date: 2012-11-14 journal: plos one doi: 10.1371/journal.pone.0048508 sha: doc_id: 317912 cord_uid: v2wovcqd background: the need for the timely collection of diagnostic biosamples during symptomatic episodes represents a major obstacle to large-scale studies on acute respiratory infection (ari) epidemiology. this may be circumvented by having the participants collect their own nasal swabs. we compared selfand staff-collected swabs in terms of swabbing quality and detection of viral respiratory pathogens. methodology/principal findings: we conducted a prospective study among employees of our institution during the ari season 2010/2011 (december-march). weekly emails were sent to the participants (n = 84), reminding them to come to the study center in case of new symptoms. the participants self-collected an anterior nasal swab from one nostril, and trained study personnel collected one from the other nostril. the participants self-collected another two swabs (one from each nostril) on a subsequent day. human β-actin dna concentration was determined in the swabs as a quality control. viral respiratory pathogens were detected by multiplex rt-pcr (seeplex rv15 kit, seegene, eschborn, germany). of 84 participants, 56 (67%) reported at least one ari episode, 18 participants two, and one participant three. self-swabbing was highly accepted by the participants. the amount of β-actin dna per swab was higher in the selfthan in the staff-collected swabs (p = 0.008). β-actin concentration was lower in the self-swabs collected on day 1 than in those collected on a subsequent day (p<0.0001). a respiratory viral pathogen was detected in 31% (23/75) of staffand in 35% (26/75) of self-collected swabs (p = 0.36). with both approaches, the most frequently identified pathogens were human rhinoviruses a/b/c (12/75 swabs, 16%) and human coronavirus oc43 (4/75 swabs, 5%). there was almost perfect agreement between selfand staff-collected swabs in terms of pathogen detection (agreement = 93%, kappa = 0.85, p<0.0001). conclusions/significance: nasal self-swabbing for identification of viral ari pathogens proved to be equivalent to staff-swabbing in this population in terms of acceptance and pathogen detection. the need for the timely collection of diagnostic biosamples (such as nasal swabs) during acute symptomatic episodes represents a major obstacle to large-scale studies on acute respiratory infection (ari) epidemiology. this may be circumvented by having the participants collect their own nasal swabs (''selfcollected nasal swabs'' or ''self-swabbing''). this method has been shown to be highly acceptable and feasible in various populations, e.g. among parents who collected nasal swabs from their children [1] or adults who collected swabs from themselves [2] (also reviewed in [3] ). while the mere feasibility of nasal self-swabbing has thus been amply demonstrated, efforts to validate the diagnostic equivalence of self-swabbing compared to staff-swabbing are still ongoing. in a sample of 38 individuals with ari symptoms, larios et al. compared self-collected midturbinate swabs with staff-collected nasopharyngeal swabs (gold standard) that were collected the same day. the self-collected swabs had a sensitivity of 86% for the detection of respiratory pathogens compared to the gold standard [4] . luinstra et al. found similar detection rates for respiratory pathogens between self-and staffcollected midturbinate swabs when one staff-collected and one selfcollected swab were taken from opposite nostrils during the same visit to a campus health center [5] . ip et al. investigated the validity of self-collected nasal (posterior nares) and pharyngeal swabs to detect influenza virus infection and came to the conclusion that self-swabs may be a good alternative [6] . while these results do provide substantial evidence for the validity of selfcollected midturbinate swabs, anterior nasal swabs have not been evaluated in this respect. moreover, self-collected nasal swabs collected on separate days have not been compared with each other. in the present study, we thus compared quality of swabbing and efficiency of viral detection of anterior nasal swabs in the following scenarios: 1) self-vs. staff-collected swabs that were taken during the same visit to the study center (day 1), and 2) self-and staff-collected swabs from day 1vs. self-collected swabs that were obtained at home on a later day. a prospective study was conducted during the 2010/2011 ari season among a convenience sample of employees of our institution, the helmholtz centre for infection research in braunschweig, germany. in december 2010, employees (18 to 69 years old) were sent messages through the internal e-mail system inviting them to participate in the study. this invitation contained a link to the institutional intranet where information about the study was made available in english and german. individuals planning to leave braunschweig during the study period and staff members of the departments of epidemiology and infection genetics were not eligible to participate, the latter due to concern over a potential conflict of interest. at the baseline visit (december 2010-january 2011), the study aims were explained to the participants and informed consent was obtained. a self-administered questionnaire was used to collect basic sociodemographic data. at the end of the ari season (april/ may 2011) the study participants completed a short acceptance questionnaire. all participants received a remuneration of 5 j. the study was approved by the ethics committee of the state board of physicians of the german federal state of lower saxony. during january-march 2011 weekly e-mail messages were sent to the participants reminding them to come to the study center within 7 days of onset of at least one of the following symptoms: sudden onset of stuffy or runny nose, cough, sore throat, headache, malaise, chills, or fever, defined as body temperature .38uc. in the study center, a trained staff member (a.g.) obtained a nasal swab (regular flocked swab, copan, brescia, italy, product number 359c) from the participant's left nostril and instructed him/her how to perform a self-swab. the participants also received written and visual instructions for nasal self-swabbing. the participants then self-collected a swab from the right nostril. briefly, the swab was to be inserted into the nostril to the point where the basal edge of the flocked tip had just entered the nostril, corresponding to a depth of insertion of approx. 1 cm. the swab was then rotated three times, being careful to swab all 360u of the anterior nasal lining and to include the superior recess (''little's area'') and the latero-inferior recess. the swab was then placed into 1 ml universal viral transport medium (copan). a swabbing kit containing written and visual self-swabbing instructions, two nasal swabs and two vials of 1 ml transport medium was then given to the participants with the request to self-collect two nasal swabs (one from each nostril) at home the next day, to place each swab in 1 ml transport medium and to return the swabs to the study center as soon as possible. the swabs were stored at 270uc until analysis. the timeline of the study is shown in fig. 1 . detection of human b-actin coding sequences was used as a measure of sample adequacy, assuming that the amount of b-actin gene dna can serve as proxy for the presence of human epithelial cells [7, 8] , which contains these b-actin gene sequences in a pcdna3.1 backbone, were analyzed in parallel to obtain the standard curve. b-actin dna concentration was determined in all four swabs. the values of the two swabs that were self-collected at home were pooled. the technician performing the laboratory analyses was not blinded as to whether a swab was staff-or selfcollected. detection of viral respiratory pathogens. rna was extracted from 200 ml aliquots of transport medium (utm kit, copan, brescia, italy) with the qiaamp minelute virus spin kit (qiagen gmbh, hilden, germany). cdna was synthesized with the transcriptor first strand cdna synthesis kit (roche diagnostics gmbh, mannheim, germany) and tested by multiplex pcr (seeplex rv15 ace detection kit, seegene germany, eschborn, germany) for the presence of any of 15 human viral respiratory pathogens (adenovirus a/b/c/d/e, human metapneumovirus, enterovirus, bocavirus 1/2/3/4, human coronavirus 229e/nl63 and oc43, parainfluenza virus 1, 2, 3 and 4, influenza virus a and b, respiratory syncytial virus a and b, and rhinovirus a/b/c), following the manufacturer's recommendations except that 4 ml instead of 1 ml cdna was used as input for the pcr reaction. satisfaction and acceptability were assessed using a nine-item questionnaire. participants rated each item on a five-point likert scale with 1 indicating strong disagreement, 2 disagreement, 3 neither disagreement nor agreement, 4 agreement, and 5 strong agreement. some of these items were reverse-phrased to reduce response bias. data were described by percentage for categorical variables and median with interquartile range (iqr) for continuous variables. a staff-collected and a self-collected swab were obtained on day 1 from separate nostrils. the participants were instructed to collect a self-swab from each nostril the next day, but the actual day of self-swabbing ranged from day 2 to day 6, as indicated by the triangle. doi:10.1371/journal.pone.0048508.g001 table 1 . acceptability of nasal swabbing. the collection of the nasal swab by the study personnel was acceptable (n = 56)* 5 collecting the nasal swab myself was acceptable (n = 56)* 5 i felt comfortable when the study personnel collected the swab (n = 56)* 5 (4-5) i felt comfortable when taking the swab myself (n = 56)* 5 i would prefer taking a nasal swab myself and not having it taken by study personnel (n = 56)* 3 (2-3) nasal self-swabbing was easy to perform (n = 56)* 5 the instructions how to take the self-swab were understandable (n = 56)* 5 i would participate in a study where nasal swabs are to be taken by study personnel (n = 77)** 5 i would participate in a study where nasal swabs are to be taken by myself (n = 76)** 5 *only those participants who collected at least one nasal swab. eighty-four participants responded to the invitation e-mail, corresponding to a response rate of 18%. seventy-two participants (86%) were women, the median age was 37 years (range, 28-46). about half of the respondents had a university degree (including university of applied sciences) and about 12% were born outside germany. overall, both staff-and self-collected nasal swabs were highly accepted ( table 1 ). most participants reported that instructions how to collect the swab were easy to understand and that the nasal self-swab was easy to perform. the participants did not make a preference regarding self-or staff-collected swabs ( table 1) . fifty-six of 84 (67%) participants reported at least one ari episode, 18 (32%) participants reported two episodes, and one participant reported three, resulting in a total of 75 ari episodes for the final analysis. the number of ari symptoms reported in a single ari episode ranged from one to seven (median, 3.0). thus, 75 matched pairs of staff-and self-collected nasal swabs, performed on the same day, were available. about 14% of these were taken on the day of symptom onset (day 1), 33% on day 2, 22% on day 3, 12% on day 4, and 19% on or after day 5. the additional set of self-collected swabs, which was to be collected at home the next day, was obtained in the majority of ari episodes (71/75, 95%), for 67/71 (94%) of which swabs from both nostrils were returned, and from only one side in the remaining four. sixty-two percent of these swabs were indeed collected the next day (day 2) and the latest one on day 6 ( fig. 1) . when comparing the staff-and self-swabs collected on day 1, bactin dna concentration was higher in the self-collected swabs (p = 0.008) (fig. 2a) . the b-actin dna concentration was higher in the self-swabs collected on or after day 2 than in the self-swabs from day 1 (p,0.0001). interquartile distance was smallest in the staff-collected swabs and greatest in the swabs that were selfcollected at home, indicating lower variability in the staff-collected than in the self-collected swabs. b-actin dna levels did not correlate with the duration of symptoms preceding the day of swab collection (fig. 2b) . a respiratory viral pathogen was detected in 31% (23/75) of staff-and in 35% (26/75) of self-collected swabs collected on day 1 (p = 0.36, mcnemar test). in both, the most frequently identified pathogens were human rhinoviruses a, b or c (12/27 positive swabs, 44%), human coronavirus oc43 (4/27 swabs, 15%) and parainfluenza viruses 1, 2, 3 or 4 (4/27, 15%). table 2 contains the complete list of detected pathogens, expressed as percentages of all 75 swab pairs collected on day 1 in which a pathogen was detected in at least one of the two swabs. there was nearly perfect agreement between the staff-and self-swabs collected on day 1 in terms of pathogen detection (percent agreement = 93%, k = 0.85, fig. 3 ). the overall sensitivity of self-collected swabs to detect a respiratory pathogen was 96%, compared to the staff-collected swabs (table 3 ). this very good agreement between the staff-and self-collected swabs from day 1 is also evident in the flow diagram shown in fig. 3 . analyzing the results obtained with the self-swabs from day 2 or later, a viral pathogen was detected in 39% (26/67) of the swab pairs when the results of both nostrils were combined. when the swabs from each side were considered separately, a pathogen was detected in 31% (21/67) of the self-collected swab from the right and in 37% (25/67) of swabs from the left nostril. however, this apparent difference was not significant (p = 0.22, mcnemar test). comparing viral detection of these self-swabs with that of the staffcollected swabs from day 1 revealed substantial agreement table 3 . sensitivity and specificity of self-collected swabs, obtained in the study center, to detect viral respiratory pathogens (compared to staff-collected swabs)*. (percent agreement = 85%, k = 0.67). the detection of a viral pathogen was independent of the amount of b-actin dna in both staff-and self-swabs collected on day 1 (fig. 4) . likewise, there was no association between viral positivity status and b-actin dna levels across all samples (p for trend = 0.943). this prospective study comparing staff-and self-collected nasal swabs for the detection of ari pathogens clearly demonstrated the validity of self-swabbing; specifically, self-swabbing was not inferior in terms of acceptance, satisfaction, sample adequacy, and viral detection rate. of note, we observed excellent agreement in viral detection between self-and staff-collected swabs collected the same day. the agreement between the swabs that were self-collected at home and the staff-collected swabs was somewhat less pronounced, but still was classified as substantial (k = 0.67). this lower agreement may be explained by the time lag between collection of the staff-swabs and the self-swabs at home, which spanned up to 6 days and resulted in five additional positive self-swabs, but only two additional negative ones. thus, taken together, the results strongly indicate equivalence of self-collected and staff-collected swabs in this study population. noteworthy differences were detected in b-actin dna concentration, which was used to quantify the amount of host cells and thus served as a measure of sample adequacy [8] . median b-actin dna concentration was significantly higher in the self-collected than in staff-collected swabs, but also in the swabs that were selfcollected at home than in the self-collected swabs from day 1. taken together, these results suggest (1) that the participants applied higher swabbing pressure than the trained staff member, likely due to high confidence in the self-swabbing procedure, and (2) that a training effect resulted in yet greater confidence and more vigorous swabbing when self-swabbing was repeated at home $1 day later. in support of this notion, in a study comparing staffand self-collected swabs that were obtained the same day smieja et al. observed a higher number of epithelial cells and a tendency toward a higher b-actin dna level in a second self-swab that was collected immediately after the first one [8] . alternatively, the presence of leukocytes in purulent secretions may have contributed to b-actin levels in some swabs. however, we do not consider this to be a major contributing factor since most participants did not have purulent secretions. another theoretical reason for the higher b-actin dna levels in the swabs that were self-collected at home might have been the longer disease duration, leading to higher shedding of epithelial cells or higher leukocyte numbers in the secretions. however, as shown in fig. 2b , there was no association between duration of symptoms and b-actin concentration in the swabs, thus ruling out this possibility in the present study. of note, more thorough sampling (as reflected by higher b-actin dna levels) did not improve viral detection in our study, suggesting that the amount of host cells on the swabs was near the optimum in most cases. alternatively, the sampling of host cells may not be a major determinant for the detection of ari viruses due to the presence of sufficient amounts of viral particles in nasal secretions. a criticism of studies comparing staff-and self-collected swabs from the same day has been that the participants might feel more confident in the presence of study personnel [10] and that selfswabs might actually be inferior when collected in the absence of study personnel. we tested this hypothesis by including two additional nasal swabs which were self-collected at home $1 day later. comparison of these swabs with staff-collected swabs collected on day 1 revealed good agreement in terms of viral detection and even better sample adequacy, thus demonstrating the diagnostic equivalence of self-swabbing in an unsupervised setting, provided that the participants have been trained adequately. it should be kept in mind that only two individuals with pcrproven influenza virus infection were detected. therefore, anterior nasal self-swabbing for the detection of influenza virus infection still needs to be validated in dedicated studies. recently, a flocked mid-turbinate swab was developed and turned out to be superior to the gold standard nasopharyngeal swab in terms of ari virus detection [8] . the anterior nasal swab used in the present study has not been compared to this midturbinate swab. this should be done in a future study. our findings are also limited by the fact that the study was conducted in a selected study population recruited within a research institution. however, the population included a mixture of scientific, clerical and support staff. notably, education level spanned a broad range and did not influence viral detection or b-actin dna levels. nonetheless, our findings need to be validated in future studies using random samples drawn from the general population. due to much lower expenses for personnel and travel, selfcollection would be a highly cost-efficient way to obtain diagnostic nasal swabs in medium and large scale population-based studies on ari epidemiology [3] . the presented study adds significantly to the growing body of evidence demonstrating its diagnostic equivalence to staff-collection. nasal self-swabbing proved to be an acceptable, feasible and valid method to identify viral respiratory pathogens in this selected adult population. its applicability in the general population should be tested in future studies. parent-collected respiratory specimens-a novel method for respiratory virus and vaccine efficacy research e-mail-based symptomatic surveillance combined with self-collection of nasal swabs: a new tool for acute respiratory infection epidemiology self-collected nasal swabs to detect infection and colonization: a useful tool for population-based epidemiological studies? self-collected mid-turbinate swabs for the detection of respiratory viruses in adults with acute respiratory illnesses evaluation and clinical validation of an alcohol-based transport medium for preservation and inactivation of respiratory viruses validation of self-swab for virologic confirmation of influenza virus infections in a community setting evidence for altered regulation of i kappa b alpha degradation in human colonic epithelial cells development and evaluation of a flocked nasal mid-turbinate swab for selfcollected respiratory virus diagnostic testing the measurement of observer agreement for categorical data collection by trained pediatricians or parents of mid-turbinate nasal flocked swabs for the detection of influenza viruses in childhood we would like to thank the participants for their kind participation in the study. we also thank gérard krause (helmholtz centre for infection research, braunschweig, and robert koch institute, berlin) and aparna schweitzer (helmholtz centre for infection research, braunschweig) for helpful comments and a critical reading of the manuscript. key: cord-034437-lore5krk authors: de kervenoael, ronan; schwob, alexandre; manson, inci toral; ratana, chatlada title: business-to-business and self-governance practice in the digital knowledge economy: learning from pharmaceutical e-detailing in thailand date: 2020-10-30 journal: asian bus manage doi: 10.1057/s41291-020-00141-z sha: doc_id: 34437 cord_uid: lore5krk this study investigates self-governance within business-to-business (b2b) in the digital knowledge economy. to do so, we elicit the engagement of healthcare professionals (hcps) and medical science liaisons (msls) with “for-profit social media technology” (fpsmt) in e-detailing. using data from 23 in-depth interviews with hcps (physicians and pharmacists) and msls in thailand, we show that e-detailing fosters self-governance as a practice. the data identify how fpsmt, as privatized social media managed by large firms, represents a tool for self-governance that is articulated by expert professionals along three cognitive frames: aspiration, regulation, and responsibilisation. through fpsmt, professionals in highly regulated b2b ecosystems engage in self-governance practice to develop pooled views that are influenced by personal and collective rules. the perspective on self-governance as a practice that is offered allows to understand how b2b network governance rely on professionals’ engagement to foster aspirations for the collective agenda, beyond the narrow pursuit of sales’ objectives. self-governance delineates the process whereby one is "having control over oneself, to act in a way that is relevant to one's own profession, to know who you are and, therefore, behave in the way your profession expects" (mctaggart et al. 2017, p. 90 ). despite widespread research on self-governance in political sciences and management literature, there is a scarcity of studies addressing the forms self-governance takes to face the needs of asian' firms within the digital knowledge economy (wang et al. 2016) . within today's hyperconnected economies, self-governance is so far depicted as accomplished through knowledge work that has often been equated to self-branding (gandini 2016; grénman et al. 2019) . in this research, we propose an enlarged view on self-governance that establishes how individuals demonstrate their sense of professionalism while appreciating existing governance structures that prevail in inter-firm relationships (chelariu and sangtani 2009) . this view allows to approach self-governance as a practice occurring in today's digitized environments that fuel innovation in settings where relationships are very tightly organized, as is the case in business-to-business (b2b) relationships (fox and ward 2008; olakivi and niska 2017) . in this paper, we investigate the unfolding of self-governance practice within the digital knowledge economy by examining the b2b case of pharmaceutical e-detailing in thailand. e-detailing represents the main access point leveraged by medtech firms via their medical science liaisons (msls) to engage healthcare professionals (hcps). it helps to manage access to information including sales content, on multiples devices, making new product information (e.g., drugs, delivery mechanisms, test studies, etc.) interactive and updated in real time. importantly, because of its strategic importance, e-detailing is strictly regulated revealing, how hcps' engagement with smt meets both novel and often conflicting expectations stemming from social media platforms owned by private large pharmaceutical brands that we call 'for-profit social media technology' (fpsmt). we analyze self-governance practice through twenty-three in-depth semi-structured interviews with msls and hcps (including pharmacists and physicians) as key users of e-detailing systems. the data show how hcps and msls are engaged with fpsmt, indicating that such technology requires them to develop their own sense of professionalism while appreciating how to comply with governance structures that concern both public (patients, governments, ngos) and private stakeholders. the findings show that digitized self-governance supports asian firms' innovation management by enabling expert professionals to articulate collaborative behaviors and the pursuit of sales objectives with the management of their own reputation. set in the framework of these broad challenges, we pursue two main objectives: (1) to address in b2b how hcps make sense of their current situations when cognising, drawing on, and leveraging their engagement with fpsmt in e-detailing; and (2) to identify the main drivers and manifestations of self-governance in practice that occur through b2b market-actors' engagement with fpsmt. to accomplish this, we adopt an approach based on framing and sensemaking that sheds light on the ambiguities and paradoxes that technology implies. we show how hcps and msls are empowered to unravel smt's unsettled structures and take actions, while at the same time, leaving scope for dissonance and situational improvisation (goffman 1974; mazmanian 2013; orlikowski and gash 1994) . we then consider the theoretical contributions by revealing insights on how self-governance operates in b2b and as a practice beyond discrete experiences or desirable states for expert individuals (gautam 2017; gandini 2016) . self-governance is found to be a fundamental resource to invigorate network governance in the digital knowledge economy. subsequently, learning from pharmaceutical e-detailing in thailand, we show how for managers, self-governance transforms organizations and management practices by supporting an innovative and socially negotiated view on technologized networks. for-profit smt for b2b market-actors' engagement in the digital knowledge economy a wide set of theories (e.g., diffusion of innovation, technology acceptance and value-added models) has been mobilized in the literature to investigate how different b2b market-actors comprehend smts, which are developed, codified, and retained to seize socially generated values that enhance knowledge management processes and help organizations compete (pascucci et al. 2018; golden 2011) . in a professional context, employees' knowledge sharing via smt is an investment in social relationships and represents individual market actor's experiential know-how (work, actions, and sociality-based practices [marwick and hargittai 2019] ) shared during social interactions (panahi et al. 2016) . real time information diffusion through shared learning experiences carries specific expectations about with whom it can be shared and what an increasingly freelance workforce can legally convey (marwick and hargittai, 2019; wegner and mozzato 2019) . in b2b, most intranets or smts are a single firm's property and strictly controlled within that firm; thus, proposing a specific knowledge partaking culture (gandini 2016; north and kumta 2018) . smts facilitate knowledge retention and monitor market-actors' internalization of company values and culture, including appropriate communication and respect of the legislation so that expert knowledge is not lost (ammirato et al. 2019) . in b2b, researchers have analyzed the changing characteristics of smt and the novel types of behavior they generate (buratti et al. 2018; siamagka et al. 2015) . macro-issues with smt have mainly related to technical hurdles (moncrief et al. 2015) , underusage and unidirectionality of tools (järvinen et al. 2012) , dissemination issues (ammirato et al. 2019) , sales performance and marketing content creation (huotari et al. 2015) , firm brand-building strategy (cawsey and rowley 2016) . at meso-and micro-levels, b2b studies have investigated smt adoption and management's understanding (sivalingam 2010) ; managers' sensemaking (rooderkerk and pauwels 2016) ; influences on business practices, sales and branding; training requirements; employee management communication (edosomwan et al. 2011 ); and individual professionals' self-branding (gandini 2016) . at this point, as smts experience hyper-growth and hype continues in b2b, the boundaries businesses establish between their employees and outside market-actors are becoming increasingly blurred, precluding the non-engagement of the latter as a viable stance (leek et al. 2016; razmerita et al. 2016) . fpsmt opposes the traditional understanding of smt as allowing any individual or group to leverage and share experiences to all without specific organizational oversight or steering capacity, thus encouraging many firms and parties to capture the potential benefits. indeed, different from the models used in e-commerce platforms (e.g., amazon), p2p (e.g., ebay) or the circular economy (e.g., gumtree), fpsmt is specifically designed to allow only selected individuals, professional groups or experts to interact and share knowledge and information. this leads to appropriation and monetisation of their ideas and data and, in effect, provides better decision support services to develop novel sales tactics, products and marketing strategies for a specific private firm (schor 2016) . within the health ecosystem, fpsmts are commonly used to cultivate corporate profiles, encourage pharmacy careers, and support over the counter (otc) brands' profiles and innovation along brand communities' properties. this importantly refocuses fpsmts on specific diseases, molecule resistance, and future innovation (unmetric.com 2019) . fpsmt privatize profits for the social media provider and socialize expenses and losses when supporting healthcare professionals (hcps) involved in knowledge sharing on b2b platforms, thus calling upon hcps to be attentive to violations of personal-professional boundaries including safeguarding accountability and trustworthiness of data storage (see hipaa rules 1 ). consequently, b2b market-actors' activities on fpsmt encourage and problematise independent individuals' social engagement in the value creation process. this engagement operates in knowledge networks and requires professionals to question and monitor the linkages between themselves and their chosen networks. as a social process, self-governance between heterogenous professionals becomes central to understanding what makes individual actions meaningful, responsible, and sustainable (de kervenoael et al. 2015) . smt usage thus reflects preferred conduct when relating to professional peers in this new labor market (edosomwan et al. 2011) . the literature underlines that smt allows individuals to work for themselves in securing employment because it is a supporting tool that emanates from the socialization process at work (gandini 2016) . within these conditions, establishing the relationships between smts and expert market-actors' engagement is difficult because economic performance levels and heightened perceptions of (legal) risk characterize the decision process (swani et al. 2017 ). on the one hand, b2b actors' engagements are encouraged, echoing the sharing economy model, which facilitates knowledge work on digitized platforms, and promotes professionals' open asset sharing, requiring outward-oriented self-development where gains/losses are often intangible and hard to measure (grondys 2019) . on the other hand, engagement in knowledge sharing depends on specific organisations' strategies (e.g., promoting corporate brands and specific selected products and hard-sell approaches) and how market-actors are affiliated with, professionals' embeddedness in pre-existing social networks (endowment effect). market-actors' engagement thus goes along with the presence of various sets of governance procedures reflecting a wider range of social values that oscillate between progressive goals and genuine cooperation to "business as usual" that combines play and work (schor 2016) . the novel recombination of knowledge and its outcomes suggests innovative behavior and becomes tangible at the individual market actor level. when learning from smts, individuals become aware of their own expert value and capacity to understand others' perspectives, "functioning as intermediaries that transform social relationships into value" (gandini 2016, p. 125) . this allows individuals to make sense of multiple demands (e.g., economic, legal or, in our case, health) placed on market-actors by the digital knowledge economy's modes of innovation, characterized on a continuum between e-topia and dystopia and questioning whether smts can promote social change (lomborg 2017) . the necessary competencies identified in smt literature are in formal areas, such as sales style and customer relationship management (ammirato et al. 2019) or telemarketing (moncrief et al. 2015) , and less formal areas, including networking, problem-solving skills, and leadership capabilities (wathne and fjeldstad 2019)-but all aim at driving socio-economic growth (north and kumta 2018) . in this context, digital transformation and smts as becoming increasingly more complex to manage (swani et al. 2017 ) and stressed rapidly evolving transformative capability building is needed among highly skilled and specialized professionals (baptista et al. 2017 ; van den berg and verhoeven 2017). b2b professionals' concerns for private and collective agenda that are present on daily usage of fpsmt calls for an understanding of their engagement in the value creation processes based on collaborative and competitive modes of conduct and how the structuring and uncertain outcomes of the latter have consequences on network governance (wegner and mozzato 2019). knowledge work can be defined as actions market-actors take to solve problems whereby not only the state or large institutionalized actors regulate behavior (i.e., going across public-private boundaries of the classical liberal movement). often, many actors operate in networks across multiple mechanisms (legal, market, and social) to foster a continuous exchange process to tackle specific complex issues for which local expertise becomes important (esmark and triantafillou 2009; parker 2007) . both convergent and divergent reasoning on what is active interaction on smt is required to cope with today's complex and dynamic knowledge economy management beyond the meso-level theories traditionally considered in governance research (burchell et al. 1991; north and kumta 2018) . as strategic assemblages, smt engagement influences how market-actors critically sense and act within specific professional domains to create a coherent knowledge framework. in support, network governance is designed to capture decentralized decision-making systems where actors are connected by ties and share power and information reflecting their practices and world views. within network governance, an actor's participation is based on recognition and trust and how both affect and are affected by the behavior of other actors (davies 2000) . studies on knowledge work in networked technologies underline the importance of positive coping together with positive computing design (clarke 2018 ), but these have often bracketed in their focus network settings in which the exercise of power, authority, and influence for "getting things done" (stoker 1998, p. 24) have to be operant. in interorganisational literature, network governance represents the knowledge used for the network's overall functioning (provan and kenis 2008; stoker 2006; . three modes of governance (shared, lead-organization, and network administrative organization) shape critical factors of broadly defined network effectiveness (i.e., outcomes not achievable by individual organizations) (mandell 1994) . within the process, three main tensions are identified: efficiency vs. inclusiveness, internal vs. external legitimacy, and flexibility vs. stability. thus, information sharing processes' communal, social nature implies a self-governance capacity embedded within a range of heterogeneous market-actors who draw potential benefits from socio-technological uncertainties and opportunities (lipshitz and strauss 1997; stieglitz et al. 2018) . within organizational ecosystems, smt communities of practice address day-today knowledge work characteristics, such as role modeling, mentoring, experiential learning, and reflection; provide developmental support that complements/enriches market-actors' existing work lives; and facilitate human/social and material (smts) agencies' intermingling (kilduff and tsai 2003; lakshman and rai 2019) . these are non-linear articulations of multiple individuals' and collective's decisions of how to gradually move information in its physical form (in our case, patient data) to digital platforms. in other words, we move beyond debates whereby governments or firms' management coerce individual self-governance through legislation or threats of regulation, leaving little room for discretion and deviation (gupta and lad 1983) or firms observing agreed standards, such as interoperability and certification, to be profitable (king and lenox 2000) . while doing this, we follow work in the area of legal innovations (see levillain and segrestin 2019 regarding 'profit with purpose corporations'). we particularly recognize firms' accountability when steering the collective. a constituency's role within a network calls for understanding individuals' self-governance as a form of their accountability to themselves. governance is no longer based on a business ethics form whereby powerful firms direct smaller suppliers; rather, it is built on every market-actor's daily activities. unlike broader governance arrangements involving governments (local or national), regulatory bodies, and supranational organizations that strongly influence the decision-making process, individual (non-heterogenous) actors employ selfgovernance at the micro level, deciding resource allocations amid an external environment's more limited influence (ojo and mellouli 2018) . self-governance, from a narrow perspective, is outlined as having control of one's own affairs and managing processes along ethical and socially responsible lines without coercion by punitive regulations (gandini 2016; gautam 2017) . it has been growingly investigated in management and marketing literature showing that individuals. self-governance, as a tenet of b2b expertise sharing, implies actors act in both private and public decision-making spheres (sørensen and triantafillou 2013). network governance can thus be applied to self-governance whereby market-actors selfmonitor their thinking and learning processes (lajoie et al. 2013) , form relationships with others (maclaren 2009) , and encourage autonomy (oshana 2005) and reflection on action (wickramasinghe 2010 ) and create new loci of power but caution against networks' negative effects, such as overbearing control and relational pressures (smt trolls, polarized views, digital bullies) (broniatowski et al. 2018 ). the study positioning, within self-governance and distributed innovation practices, reflects a framing situation on e-detailing in which smts and associated ecosystems can be considered as conceptual tools (gal and berente 2008) . e-detailing is the main access point leveraged by medtech firms via their medical science liaisons (msls-previously sale rep) to engage hcps. it digitizes access to sales marketing content, mainly on mobile devices, making new product information (e.g., drugs, delivery mechanisms, test studies, etc.) interactive and updated in real time. it allows instantaneous data collection and tracking, generating a tailored high-quality experience for hcps. e-detailing can facilitate awareness of specific products, but at the same time, it can create blind spots when data monetisation emerges from privatized access and strategy (as with fpsmt) and prevent a reasonable assessment of the global picture needed in therapy. e-detailing engagement and management encapsulates both promises and dilemma calling specifically for an investigation on self-governance accomplished by expert professionals who have to work on a daily basis to shape appropriate conditions for emerging actions along the problematized principles of legitimacy, efficiency, democracy, and accountability (hennart 2015; li 2003; wedeman 2011) .the leading pharmaceutical firm's (e.g., the smt platform provider) position orchestrates the market-actors' endeavors, collective actions and network conditions for specific purposes. framing embodies and structures the professionals' choices and reveals how they process information and it resources and interact with peers (orlikowski and gash 1994) . beyond framing's technological interpretation, it incorporates the dynamic progress, uncertainties and inconsistencies smts represent (van burg et al. 2013) . framing, or frame creation, and sensemaking are considered complementary processes for understanding how market-actors can negotiate smts as a structuring context in which they are voluntarily embedded. goffman (1974) viewed frames as abstractions that allow the configuration or structure of information meaning. the active process of seeking, processing and integrating information is labeled sensemaking (wilson and wilson 2013) . frames allow multiple (at times, contradictory) interpretations of shared smt resources to become compatible and strengthen the voicing of tension (positive and negative) and encourage unusual solution searches. through combined framing and sensemaking, we can understand and articulate how market-actors draw on formal and informal resources others create (caughron et al. 2013) to impose a sense of control and decorum on themselves in a given ecosystem. at the field level, framing allows interdependent market-actors to adopt uncommon answers to complex issues according to their beliefs (cornelissen and werner 2014) . in highly regulated b2b ecosystems, sensemaking requires individuals to recognize the abstract resources they need and the organizational constraints they face. as a first step, this requires seeking, noting, and integrating new and often counterintuitive information that challenges one's original beliefs and attitudes (weick et al. 2005) . then, sensemaking demands interaction and information sharing to capture the crowd's wisdom and guard against unintended data disclosures (surowiecki 2005) . in sum, one can use framing and sensemaking to appraise market-actors' social relationship investment and engagement processes. understanding this ambiguous refocusing process and how multiple actors' selfgovernance is practiced forms this study's core (nalini et al. 2017 ). e-detailing, like all technologised practices, requires understanding not only technology acceptance (abdekhoda et al. 2014) but also this acceptance's underlying meanings, including how health information management is negotiated within networks (ehteshami 2017) . at stake here, along with market pressures and innovations, is the understanding of how some platforms set up by facilitating private firms require the engagement of hcps and their genuine willingness to positively contribute to the collective agenda that in essence raises drugs status away from a commodity to a valued innovation. overview following yin's (2015) and eisenhardt's (1989) guidelines, we present a case study on e-detailing in the pharmaceutical industry to theorize self-governance as a practice based on b2b actors engagement with fpsmt in highly regulated contexts that has far-reaching implications for other industries such as banking, insurance or power generation. case studies are recommended for unfolding events bounded by a specific time, multiple actors, and tasks (i.e., "a program, an event, an activity, a process, or one or more individuals" (creswell and creswell 2017, p. 15) . a qualitative research approach was used to collect and analyze the data (miles and huberman 1994) . the unit of analysis in this study is represented by three types of healthcare professionals, namely pharmaceutical salesforce called medical science liaisons (msls), physicians and pharmacists, representing the key current active market-actors engaged with fpsmt on one particular global pharmaceutical firm e-detailing platform. we apply established conventions of qualitative data analysis involving (1) categorization, abstraction, comparison integration, and abstraction searching for patterns in the data and why those characteristics are there towards consolidated meaning, and (2) interpretation, along essence-capturing of the essential elements of the stories connections (spiggle 1994; ng and hase 2008) . our interpretative analysis draws on 23 in-depth interviews conducted in thailand, an emerging asian market chosen because of the diverse and urgent healthcare issues it faces. deloitte estimated health care spending in thailand would reach $18.7 billion in 2018, growing by 8% between 2014 and 2018. this was higher than malaysia's 4%, indonesia's 3.1%, myanmar's 1.8%, and the philippines' 4.4% and was on par with singapore (oxford business group 2020). in thailand, more than 70% of the population receive free health care under universal health coverage, and the country is rapidly becoming a competitive destination for medical tourism. moreover, private hospitals are raising funds and expanding overseas (oxford business group 2020). thailand has received recognition for its quality healthcare services, placing sixth (67.99/100) in ceoworld's 2019 health care index out of 89 countries (ireland 2019) . of the various subsets (all out of 100), thailand received a score of 92.58 for its healthcare infrastructure, 17.37 for professionals' competence, 96.22 for healthcare cost, 67.51 for medicine availability, and 89.91 for government readiness (bangkok post 2019). thus, e-detailing strategies seem to contribute to raising the somewhat lower scores for professional competence through thailand's government establishing proactive policy strategies, making it the medical hub of asia. moreover, one key challenge the thai healthcare system faces is to advance the capturing of accurate health data from different stakeholders to better plan and control spending. in data rich healthcare, e-detailing, if properly overseen, could foster sustainability of public healthcare expenditure (khidhir 2019) . one of this study's authors had full access to msls at a global pharmaceutical firm in thailand. this allowed direct observation of daily services practices from its headquarters during video calls and face-to-face visits with hcps. this access provided a solid foundation to observe individual practices, and meaningful interactions. an initial pilot study was carried out through three interviews. a semi-structured guide was created cycling between the pilot study and the literature (davis and eisenhardt 2011) . interviewing follows purposeful sampling (teddlie and yu 2007) . interviews were recorded with the interviewees' consent; when required, one of the researchers carried out translations, with pilot study respondents crosschecked for validity. subsequently, an interview request was sent to 36 hcps if they had at least 15 interactions on the e-detailing platform (internal data); however, 13 of those declined participation for various reasons. for those that agreed, they were contacted via email and the generic topic was explained, along assurances of confidentiality and that ethical guidelines of the interviewing researcher's university would be followed. therefore, we conducted a series of 23 in-depth interviews (face to face or via video links) with six physicians, seven pharmacists, and 10 msls (from a single global pharmaceutical firm) (see the appendix). respondents were from either public or private hospitals and had, on average, eight years of experience and were, on average, 32 years old; this was deemed appropriate to reflect and manage the complexity of the analytic task. all interviews were analyzed using the criterion of information saturation and redundancy (lincoln and guba 1985) . detailed notes were taken of specific examples shown by the hcps (including screen shots of specific information on the e-detailing platform), photos of older leaflets, photos of how files were organized at the individual level, photos of it equipment available, and displays of any drug or pharmaceutical firm names, if available. the aim of the interviews was for deep understanding of the interactions at stake in the e-detailing service, including the demands the informants perceived were put upon them (mccracken 1988) . twelve interview questions were divided into three parts: (a) how hcps engage, or not, with fpsmt; (b) how hcps change, or not, their work practices to echo the concepts of technological framing; and (c) how sensemaking engage hcps towards self-governance (järvinen et al. 2012; kianto et al. 2016; siamagka et al. 2015) . moving from general to more-specific questions, we asked about hcps day-to-day experiences with e-detailing, including their experiences on pharmaceutical "x" e-detailing platform; approaches and managing the acquisition, creation, sharing, and retention of information; how those issues affect accomplishing their work (i.e., relevance of knowledge, effective process of knowledge evaluation and knowledge protection ability; evolvement of the fpsmt process with other professional actors (e.g., mutually beneficial decision-making process; better understanding of other market-actors' views regarding dispute resolution; daily practices and opportunities with "x" smt and any restrictions or challenges they faced). content soundness was ensured by linking the semi-structured interview questions to the theoretical framework and through unpacking the framing and sensemaking processes in which market-actors' engagement in fpsmt becomes effective and self-governance is practiced. the protocol was reviewed by three experts within the global firm and was pre-tested by a representative of each profession, each of whom had more than 5-years' experience in healthcare. (after piloting, hospital managers and policymakers were not interviewed because they represented a more accounting-based view and were not directly involved in daily smt activities.) to analyze the data, the authors systematically read the transcripts to search for ideas, patterns, common ground, and opposition within the respondents' answers. the analysis procedure included four steps: (a) researchers independently coded the practices identified through the interview transcripts and notes into preliminary working categories of informant-centric terms using nvivo version 10 to generate first-order themes; (b) shifting between the data and the literature (santos and eisenhardt 2009), second-order themes (corbin and strauss 1990) were developed; (c) the second-order themes were refined by cycling between theory and the field data (davis and eisenhardt 2011); at the end of this stage, three frames (aspiration, regulation and responsibilisation) were formed, and a framework was developed to demonstrate the relations among these concepts (see fig. 1 ). initially we used open coding that generated a large number of open codes including for example: 'assertiveness to fit in', 'technology commitment and professional image', 'tenability and accuracy', and 'e-detailing access and manipulation focuses'. leveraging these multiple open codes, we mapped the mosaic of narratives without imposing a pre-imposed perspective (yin 2015) . the data revealed more details, and comparing the hcps led to pattern and commonality recognition, such as respondents' underlining matters associated with information trust, it-mediated information types (videos, graphs, photos), 'technological savviness', 'discussion modes standardisation' and 'information benchmarking and comparability'. by merging these materials, a higherlevel classification, 'expansion of content trustfulness' emerged. from that, we axial coded to identify central phenomenon (davis and eisenhardt 2011) and introduced additional search regarding specific positive and negatives examples about the challenges and opportunities faced on e-detailing to saturate the emerging higher-level classifications. following colliander and wien (2013) , the authors discussed the findings and resolved disagreements (ng and hase 2008; spiggle 1994) . in the last step, we theorized on these higher-level categories along the attributes highlighted in the literature review, leading to developing our three frames. the findings reveal that hcps (pharmacists, physicians and msls) identify and seize opportunities offered on fpsmt in ways that disclose different reflective states through which along micro-practices self-governance practice is accomplished (see fig. 1 ). the conceptual figure describes how market-actors develop a sense of purpose and appreciate the extent to which fpsmt continuously affects their own initiatives and development. as a reflective state, self-governance, through the questioning centered on each frame, encourages purposeful actions that ultimately foster active quests for relevance. the double-headed arrows in our framework represent the quests (i.e., self-governance practice as projects), which are often only partially resolved, leading market-actors to move to another frame. the three intertwined cognitive frames are labeled aspiration, regulation, and responsibilisation frames. the granularity of fpsmt is found to support market-actors' abilities to manoevre within multiple levels of competing rationalities, which then delineates the instantiation of self-governance practice. in each frame, we characterize the key micropractices, understood as individual activities abstracted from their specific context or time of application to appreciate how a phenomenon (here, self-governance) is instantiated. when being framed, these establish a teleoaffective structure toward self-governance as an integrative practice (rouleau 2005) . micro-practices are understood as individual activities that have been abstracted from their specific context or time of application to appreciate how a phenomenon (here self-governance) is instantiated (rouleau 2005) . the respondents first revealed healthcare professionals rely on smt to generate strong aspirations. still, this aspiration frame relates both the humbling experiences and doubts about seizing control over one's career trajectories, competencies and effectiveness the development of fpsmt generates. under this frame, respondents appeared to be critical towards fpsmt's present usage (i.e., current rules and obligations are considered problematic). the following quote from respondent i illustrates that cognition triggers a readiness to be critical on the current state of fpsmt. however, both respondents i and b pointed towards novel micro-practices that encourage the development of social agilities based on interactive, dynamic communication and trust in self-governance purposes. respondent i (pharmacist): i found fascinating that the detailed video showing how available drug molecules can deliver to targeted organs. it is very clearly explained and also encouraged me to understand it better, maybe from another perspective and in greater detail. it encouraged me to discuss, share and comment [on] the video with others to create further value. respondent b (physician): i can update to the new guideline of treatment and get the knowledge from the most famous professor's experience, all shared on one sm platform. i can adapt that information to use with my patients. i questioned myself. this application helped my hospital to save time and cost. it is real progress for all. these market-actors displayed an obvious enthusiasm for smt functionalities that change and strengthen network members, hence, positively enhancing their self-presentations. for most hcps, technology-mediated interactions are related to the willingness to deepen content quality, which is directly linked to the inseparability of hardware, software and resource creation that facilitate the "professional social game." this frame supports the affordances of technological tools that articulate both individual and collective aspirations, including developing capacities to confront change. hcps feel empowered by fpsmt they can use to answer multiple questions about the directionality and prescription of what is then a prescriptive disseminating tool. with professional fpsmt usage, hcps must adopt a higher level of vigilance and prudence compared to private smt usage. the aspiration frame reflects what the mastery or obligations related to fpsmt (demands and expected outcomes) calls for in terms of smt's scope and how to engage with it (e.g., assessment, conformity or deviation) when considering higher-order interests and flow of experiences. through this reflective process, the aspirational values that individuals share on fpsmt are not suppressed by the personal risks these technologies epitomize; on the contrary, they are embraced towards innovation. however, respondent h voiced an awareness of the danger that may come from adverse event cases. i used e-detailing smts […] to provide information to doctors, but often needed to smooth the discussion because of internet signal issues and legal requirements…. if a salesperson is not familiar with e-detailing or ipad technology, he will not use it naturally, the knowledge of technology itself is an issue. this can cause professional image damages. but it is getting better, and everybody can see that! the aspiration frame subsequently involves making sense of the contradictions included in fpsmt's daily usage. this is akin to imposing a constant oversight reflecting "perceived absolute" demands (e.g., respect of the legal framework) beyond the innovative mindset that encourages active actors to make sense of direct interactions. overall, the aspirational frame allows market-actors to work on professional sustainability and the development of content accuracy, and it even asserts specific firm's technological savviness, as respondent h explained: slides presentation and sponsorship must be approved by [country level organisation] medical first and the legal guys [within the firm]. slide presentation cannot have [a] trade name appearing because we are not doing business only but [must] focus on education and needs for information. then we need to be very clear among ourselves on what we say how we interpret what is written. otherwise, our jobs could be at risk. this forces all of us to reflect on what and how we want to use the material and how physicians will interpret and react to what is said. although this quote reveals a fearful side of communication and misuse of privilege, respondents accentuate a possible set of reasoned usage that, as a group, they feel exposes the learning scope on fpsmt. here, aspiration expresses the social nature of networks grounded in experience-based reassurance. in the regulation frame, respondents elaborated on the corollary of the relative empowerment described in the aspiration frame. in this frame, market-actors are better equipped to appraise their need for regulation for both formal and informal communication and sharing rules. as such, smt is perceived as not appropriately or sufficiently scrutinized (towards correcting errors or incorrect information), especially when mutual support could clearly lead to richer, more valuable outcomes. going beyond stereotyping, substantial concerns exist about the security of smt (including privacy issues) and about the (de)legitimisation of legal issues, as evidenced in respondent p's remarks. in my opinion, there are many concerns… perhaps, confidentiality concerns, security network, accuracy and reliability of the information should be made clear when using digital media. it is about "patient's rights" because if users took a photo of a patient or shared a patient's opd card on the platform or sent to others without erasing/blurring the patient's name/face, it would be illegal and violate the patient's rights. it is about accuracy concerns. to get rapid feedback on things[,] because if pharma marketers publish any mistakes, despite all the checks; or incorrect information, danger can spread very quickly, and the problem will be very hard to solve, smts seem to have a tendency not to let information even false [information] be erased. indeed, respondents developed various dispositions and sensibilities towards fpsmt guidelines and status beyond the blanket notice-and-consent model. most respondents discussed the necessity of instigating, fostering and achieving protocols that do not curb communication, so that knowledge diffusion occurs, as respondent n shows. it surely supports pharmaceutical marketing but also innovation. we need it. i always search for medicine information on the doc. they share, but often i am not able to find much beyond normal information on traditional leaflets. thus, i think that if pharmaceutical companies upload more information about their medicines or delivery mechanisms on their platform, we will conveniently access that essential information, will participate [in feedback, reviews] and use the drug, if appropriate, in our work. caught by the regulation frame, market-actors' self-governance practices tend to touch on both legal requirements and social communication expectations, demonstrating a need to further externalize fpsmt social evaluation across a broader set of actors. this frame allows market-actors to shape suitable strategies and, concurrently, be considered valued and trusted pioneers. still, when actors engage in and challenge complex sociotechnical values, they recognize the unequally distributed risk to an individual's reputation. this encourages them to scrutinize specific market-actors', like the government's, initiatives, as respondent k mentioned. generally, rather than describing inertia, the regulation frame calls and relies on the other two frames (aspiration and responsibilisation) to shape market-actors' selfgovernance directionality and prescriptions towards fully exploiting what fpsmt can bestow on them. thai regulation has many particular rules about digital communication. therefore, maybe one isn't brave enough to be the digital marketing leader among the pharmaceutical industry in thailand. we are not all equal according to the government policies [,] you know. but we all need a voice, and we know stuff; the society needs it. this frame provides further evidence that market-actors work along an enquiring continuum and are thus aware of fpsmt usage's transformative and far-reaching implications on healthcare. this frame calls market-actors to problematise their engagement, which allows more socially valuable networked e-detailing practices, as respondent h noted. all actors may resist [smt] change. in my opinion, sometimes it is too quick to change [,] but it is required to keep up with innovation and encourage improvement. i am familiar with the existing e-detailing, but all the time[,] i have to re-learn through physicians' comments and views. value must be developed together. the data illustrate that reflections are open on the exclusive charters and conditions in which healthcare professionals operate. respondent a illustrates the thin line between grounding privileged communication and the carelessness of actions on fpsmt. within the responsibilisation frame, time (or the lack of it) is a precious resource for all market-actors and is a central mechanism in fostering (or not) robust interactions. as such, respondent a's quotation illustrates timely contextual actions' saliency, revealing market-actors must operate in symbiosis with the dynamic environment. this attempt to reach unification through fpsmt's use is portrayed as depending on responsible, collaborative learning as an impetus for communication that creates knowledge flows beyond facts. digital media absolutely support marketing of pharmaceutical companies. they do not only benefit them but also benefit patients because it is a necessary condition to share information in modern medicine. pharma firms use digital media such as media graph and e-detailing to create contents, spot patterns and gain best physicians' attention, but nothing is straightforward. the next quote from respondent q illustrates concerns that responsibilization must transpire across all market-actors (not only privileged ones) who adjust their behaviors and performance accordingly while recognizing that more traditional and differently codified offline practices (here, conferences) must be combined with the emerging new systems. : i cannot answer how much a webcast can influence a specific doctor's belief and behavior. i think this is the salesperson's responsibility to follow up again and again maybe face to face or at a conference as we are creating behaviors. i find out information, with statistics from the platform after the webcast is finished about the actions taken or not taken. it is about developing comfortable communication. it is not one system or another. taken together, the three frames and sensemaking processes represent three pairs of binoculars b2b market-actors leverage in interpreting the unsettled communication on fpsmt within the healthcare ecosystem. these allow them to sustainably shape actions and engage in the digital knowledge work economy. the paper sets out to investigate how self-governance practice allows professionals in the digital knowledge economy to leverage smt within highly regulated b2b environments while actively engaging in continuous knowledge work. specifically, we show empirically how, in the case of healthcare in thailand, such engagements operate in e-detailing. in doing so, self-governance practice is found to be generated through hcps and msls' reliance on cognitive framing. it allows hcps and msls to strengthen their position within fpsmt mediated practices. in the context of the highly regulated b2b healthcare social media ecosystem, the data emphasize how through the interdependence of three specific frames, self-governance operates as a practice leading to: (a) aspiration related to the benefits of being trusted, (b) regulation in ways that allow to appreciate formal and informal rules and (c) responsibilisation representing smt's context internalization for daily usage and viable engagement in e-detailing practices. the three frames are akin to a process accentuating every market-actor's voice, richness, and role in open strategisation and organizing practice, in effect bringing professionals together (whittington et al. 2011) . fpsmt for self-governance underlies a range of possibilities for expert professionals related to where and how to positively contribute to the healthcare ecosystem beyond contingencies related to the here and now (i.e., complacency) (broniatowski et al. 2018) . it illustrates how distinct professional actors legitimize or delegitimise emerging digital practices (e.g., knowledge re-use, distributed leadership) by voicing opinions, expressing empathy, or relying on daily tactics. collectively, the frames explain how engagement with privatized smt incorporates information sharing through sensemaking in knowledge economies. this leads individuals to a more organized sense of self-governance (burchell et al. 1991 ) and ways to cope with the inventive features of networks in a digital era. while analyzing the healthcare sector in thailand, this research contributes to the management literature by bringing a novel understanding of self-governance in the digital economy in two main ways. first, we give account of how selfgovernance operates in b2b contexts. second, by delving into a cognitive framing approach, we bring to the fore a novel understanding of how self-governance for professional actors in the digital economy unfolds as a practice. over the last decade, self-governance has primarily contributed to significant research in political sciences (ostrom et al. 1992; sørensen and triantafillou 2013) , management (gautam 2017; johnson et al. 2020; park 2020) , and marketing (gandini 2016; grénman et al. 2019) . in doing so, it has largely ignored the forms self-governance take in digitized b2b contexts whereby the sense of professionalism is underpinned by the extensive set of tightly organized relationships and networked imperatives that are reflected in day-to-day managerial work (fox and ward 2008; chelariu and sangtani 2009; olakivi and niska 2017; macheridis and paulsson 2019) . this study bridges this gap by proposing a view on self-governance that accommodates the increasing development of smt within and between firms and the often conflicting expectations expert professionals face when being engaged in exchanges that advance both private and public interests (wegner and mozzato 2019). we show how self-governance as a digitized practice unfolds in situated practices through which professionals negotiate stakes related to personal aspirations, responsibilities, and regulatory concerns. as such, we offer an understanding of self-governance as a practice that places professionals as major actors on both private and public agenda who demonstrates a sense of professionalism by going beyond self-interests (gandini 2016; gautam 2017) . the data show that b2b market-actors are often encouraged to step into new roles they might initially find unfamiliar and that have to be established to meet collective needs. dispersed expert professionals are critical sources of knowledge, interpretation, and elucidation. they shape complex social codes, rules, and technologies, including smt, towards developing original, often unprecedented solutions with far-reaching effects on different dimensions of the corporate innovation process, reputation, and control beyond the narrow pursuit of sales' objectives (wider et al. 2018) . hcps are now extensively embedded in their ecosystems, where different types of sustainable solutions can coexist, and where a wider array of expert professionals are able to keep momentum to influence the decision-making process. beyond the healthcare sector and asia, this research underlines that expert professionals' engagements via self-governance conjointly serve professionals individually, the collective agenda, and specific business dimensions (e.g., perception of products and service quality). self-governance becomes here a central resource for network governance. we thus contribute to network governance research by showing the conjoint roles of innovative governance structures (e.g., fpsmt) and professional engagement in the shaping of effective network governance. we specifically underline the worth of a practice-based view on self-governance to articulate the collaborative and competitive modes of conduct that prevail in network governance explicitly in highly regulated contexts (wegner and mozzato 2019) . considering that this study has been conducted within a single country, its findings provide avenues for further research. given the rapid development of e-detailing and b2b social media in asia, a longitudinal approach may capture the ever-changing nature of situated practices related to self-governance. it would be also important to enhance the understanding of the roles played by various information technologies in self-governance practices. future studies comparing managerial stances across organizational departments in b2b can add to the understanding of self-governance and network governance by exploring various countries and types of industries including the less regulated ones. following the same logic, studies can investigate self-governance as a resource through which professionals negotiate governmental regulations in the case of non-mature marketplaces (e.g., second-hand goods or promotion of alternative lifestyle). finally, to provide a more balanced view on how expert professionals draw on self-governance within networks, future research could determine how self-governance via social media platforms operates along various professional positions from trainees to ceos. in relation to this, we call for specific research on self-governance that investigates professional actors whose actions on privatized social platforms led to negative consequences for them (e.g., job loss). for managers, our research shows that innovative governance structures in the digital economy, such as fpsmt, are powerful in developing expert professionals' confidence and autonomy. professionals are indeed found to be going beyond what is strictly regulated and develop knowledge structures favoring innovations. under these conditions, firm strategies can mobilize expert professionals to balance the voices of influential groups (e.g., scientific committees, lobby groups etc.). our research echoes managers' challenges reflected in demand-side activities related to economies of scale or network effects when attempting to foster more inclusivity to forge a navigable path to collective welfare and innovation (swani et al. 2017) . consequently, this study shows that on privatized and public smt, b2b professionals are expected to go beyond mere views of information towards contributions to knowledge production. in sum, each professional is called to reflect on his/her active steering participation (e.g., boycotts, resistance, compliance etc.) to influence network-level changes (coyle 2017 ). the findings suggest that self-governance and privatized social media technologies (e.g., fpsmt) are at the core of a broader and deeper debate regarding professionals, firm and collective accountability, and the ways they question the value of globalized wealth sharing and associated impacts on business models. in the pharmaceutical sector, executive boards and leading ceos will need to appreciate the worth of collective ways that foster innovation within more inclusive service orientated approaches. e-detailing now departs from push marketing strategies as it does not lock in actors and fosters individuals' openness to alternative solutions (ehteshami 2017; kwak and chang 2016; nalini et al. 2017) . along shifting regulations, key stakes for b2b firms are to enact relevant performance indicators (e.g., number of views, number of document downloads etc.) and associated rewards for mlss. the study shows the relevance for firms in emerging market conditions to facilitate the understanding of how e-detailing technology operates (e.g., tracking and adjustments of data in real time, regulatory constraints and prevailing netiquette). spotting problematic behaviors allows firms to limit the occurrence of adverse events by taking early corrective actions, which in turn could limit the perceived intrusiveness of governments' interventions. coming to the case of e-detailing in thailand, it is essential to underline that hcps' possible non-engagement may endanger the country's healthcare system (oxford business group n.d). indeed, the findings underline that the local public and private hospital management is welcoming digital access to support modern medicine. at stake here is the welcoming of individual expert professionals' voices that contribute to bring medical solutions in all parts of the country and allow medicine sales to fit better with demand. conveying local information appears here as being essential to strengthen healthcare system's responsiveness and be less vulnerable to unanticipated events such as pandemic (e.g., or natural disasters. this implies that the thai government develops a robust healthcare system by documenting all the processes and harnessing data to support expert professionals' reskilling and upskilling capacities (bangkok post 2019). conflict of interest on behalf of all authors, the corresponding author states that there is no conflict of interest. information technology acceptance in health 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sci doi: 10.1016/j.ijnss.2020.08.002 sha: doc_id: 278860 cord_uid: nplrx07z objective: this article aims to provide an in-depth analysis of the concept of self-care and outline its defining attributes, antecedents, consequences and empirical referents. methods: the literature was searched electronically using databases such as cinahl, medline, psych info, eric, sciencedirect, amed, ebsco (health source: nursing and academic edition), sage, ujoogle and google scholar. articles from 2013 to 2020 were searched to target recent and up-to-date information about the definitions, attributes, antecedents and consequences of the concept of self-care. walker and avant's framework was utilised to analyse the concept of self-care. results: the results of the concept analysis identified seven attributes, namely process, activity, capability, autonomous choice, education, self-control and interaction. the seven identified antecedents are self-motivation, participation, commitment, resources, religious and cultural beliefs, social, spiritual and professional support, and the availability of time. the consequences are the maintenance of health and wellbeing, autonomy, increased self-esteem, disease prevention, empowerment, increased social support and the ability to cope with stress. conclusions: the result of the concept analysis was used to describe a model to facilitate professional nurses’ self-care in the intensive care unit. dorothea orem, a nursing theorist, pioneered the concept of self-care in the self-care deficit nursing theory between 1959 and 2001. the concept is well defined as "the practices that the individuals initiate and perform to maintain their life, health and wellbeing" [1] . despite the definitions presented by orem and the world health organization, there is still a need to explore and further clarify misinterpretations of the meaning of 'self-care' in the nursing profession [1] [2] [3] . the concept of self-care is known as a process, a movement, a framework, a phenomenon, a theory and a model. this concept is also used in different perspectives, including many health disciplines, nursing practice, research and nursing education. different definitions led to confusion, misinterpretations, and ambiguousness amongst healthcare providers. this resulted in the meaning of self-care becoming ambiguous, not being prioritised and self-care activities not being practised by professional nurses. the concept of self-care was then regarded as being selfish and a luxury. this was evidenced by this concept's frequent use in clinical practice, yet it was often misinterpreted and misused by professional nurses. several studies on the usability of the theory of self-care indicated that this concept is mostly being applied with various chronic medical conditions such as diabetes and cardiac conditions, to educate, emphasise and motivate both patients and their families about the importance of selfcare. the professional nurses' focus was principally on promoting patients' health and preventing their diseases by reinforcing a healthy diet and exercise [4] [5] [6] . the findings of a study conducted by leão, et al revealed that the concept of self-care was neglected by most healthcare professionals [7] . these findings indicated that the healthcare professionals dedicated most of their time to the wellbeing of other vulnerable people, while putting their self-care priorities second; especially those activities that rejuvenate and refresh them [8] [9] [10] . the results of this study led to the concept of professional nurses facilitating self-care in the intensive care unit (icu) setting, to clarify the concept and encourage the practice of self-care activities. further clarification of the meaning of this concept is required to eliminate any ambiguities and encourage consistency in practising self-care activities while caring for critically ill patients. self-care is an essential concept in orem's theory and also in the clinical nursing j o u r n a l p r e -p r o o f practice; as a result, facilitating this concept will promote professional nurses' compliance in practising self-care [1] . the concept of self-care has commonalities and differences with other concepts such as selfregulation, self-management, self-monitoring and self-efficacy. this article serves to analyse the concept of self-care to provide a better understanding of the concept and to differentiate the concept from other related concepts. according to polit and beck, concept analysis refers to a systematic process whereby a concept is analysed to identify the boundaries, definitions and dimensionality for that concept. the defining attributes distinguish concepts from other similar concepts [11] . concept analysis occurs in two phases, namely concept identification and definition, and classification of central and related concepts. the concept of self-care has been neglected by most nursing professionals as they focused primarily on the nurses pledge of service, which states that patient care is their first consideration. this has resulted in misinterpretations and misunderstanding of the concepts 'patient care' and 'self-care'. some nursing professionals regard self-care as being selfish, and this results in stress, depression, feelings of worthlessness and feelings of helplessness [12] . analysing the concept of self-care will thus enhance understanding of the concept, its use and the practice of self-care activities amongst nursing professionals. walker and avant's method of concept analysis was used in this article to define the identified concept, identify the uses of the concept, identify attributes and related attributes, describe antecedents and consequences, construct a model case, contrary case, borderline and additional case [13] . the objective of the study was to define the central concept of professional nurses' facilitation of 'self-care' in the icu and how it can be facilitated by professional nurses in the icu. j o u r n a l p r e -p r o o f walker and avant's method of concept analysis was used in investigating the concept of selfcare in detail, along with its meanings and uses in order to differentiate this concept from other concepts that may be similar but subtly different [13] . the modified method has eight steps, which include selecting the concept, determining the aims of analysis, identifying uses of the concept, determining the defining attributes, identifying the model case, identifying the additional cases, identifying antecedents and consequences, and defining empirical references. the concept of self-care is used mainly in nursing practice, in different disciplines in health, in nursing education and research. in south africa, the self-care concept focusses primarily on patient nursing interventions, and there are no organisations, such as the american nurses association (ana), which prioritise professional nurses' health and self-care [14] . the j o u r n a l p r e -p r o o f concept of self-care can be defined as a purposeful act that is often initiated and performed by an individual on their own to care for oneself without consulting a medical professional or receiving other assistance [15] [16] [17] . an individual chooses to practice self-care activities within a specified time frame. these activities are then incorporated to promote good health, maintain personal wellbeing and for continuing development throughout the individual's life. the ability to engage in self-care to meet the requirements for human functioning and development is known as self-care agency. certain fundamental conditioning factors, such as gender, age and culture can affect the individual's self-care agency [1, 3, [18] [19] [20] . related concepts. in the literature that was searched, the following terms were used interchangeably with the concept of self-care: self-management, self-compassion, selfefficacy, self-regulation and self-monitoring. self-management is a subcategory of self-care which empowers the individual to take charge of their health and manage their own conditions in nursing. self-management involves self-regulation skills, such as having the ability to manage lifestyle changes and maintain an appropriate level of nutrition, exercise and diet, and disease knowledge, while self-care focuses on daily activities performed by an individual [21] [22] . there is also a distinction between self-care and self-compassion. selfcompassion is defined as having an attitude of kindness and consideration about oneself and a mindful awareness directed towards oneself in situations of suffering. the elements of selfcompassion include self-kindness, common humanity and mindfulness, while self-care is the actions of treating oneself with kindness and compassion. at times, individuals can go through the process of self-care without being compassionate to themselves, so selfcompassion can be regarded as a moderating variable that strengthens self-care ability [23] [24] [25] [26] . self-efficacy refers to the belief in an individual's ability to organise and implement actions [27] . self-regulation is the efforts made by individuals to control and modify their thoughts, emotions and behaviours according to requirements in order to achieve self-care goals without intervention from external sources. self-care comprises of both self-regulatory activating and inhibiting components, and are the actions taken to exercise control over internal behaviour [28] . self-monitoring is a component of self-care whereby an individual measures their vital signs and symptoms, self-adjusts their treatment and lifestyle as a result of self-awareness [29] . attributes are the characteristics that consistently appear when the concept of self-care is present or is being defined in the literature, and assist in clarifying that concept [13] . the following attributes of self-care were identified through intense analyses of the subject literature: process, activity, capability, autonomous choice, education, self-control and interaction (fig 2) . the first attribute of self-care is that it is a process of looking after one's self, characterised by long-lasting personal benefits such as physical, mental, emotional and spiritual wellbeing [8, 15] . as an activity, self-care involves practising physical, emotional, spiritual, social and professional self-care activities. these activities are performed by individuals on their own behalf to preserve health and life. the activities are learned, situation driven, directed towards achieving specific goals, and performed by individuals. the activities are incorporated into our daily lives. as a capability, self care is an action directed towards universal needs, goals, and health problems [5] . an autonomous choice is taken by an individual to maintain a quality life in a responsible manner [30] [31] . it involves personal aspects such as interpersonal relationships, religion, leisure and family activities, and physical activities like healthy eating and preventative health consultation [19] . self-care is an individual's choice to make and include the formulation of self-care goals. self-care education is the essence of self-care as it leads to information and increased health literacy. interacting with friends, family, and other members of the health team is vital in self-care and ensures collaborative self-care efficiency [32] . selfcare requires self-control and discipline to achieve specified goals and to perform physical activities such as exercises. interacting with family members, friends and other members of the health profession encourage social, spiritual and professional support. the following section provides the model, borderline and contrary cases, according to walker and avant. all the attributes identified of the concept 'facilitation of self-care' contributed to the construction of a model case. the model case represents practical examples of the identified attributes and is described next. sr joy (pseudo name) is a professional nurse aged 47. she is icu trained and works in a busy trauma unit in one of the largest hospitals in gauteng province (south africa). her duties entail shift leading and supervising other nursing staff to ensure quality patient care. she is also a single parent of two teenagers still attending school. she works 12-hour shifts, alternating both days and nights from monday to sunday, and hardly has any time to spend with her family. she is obese, with a body mass index of 39, and her weight is 100kg. she is always stressed and exhausted and has resorted to buying takeaway meals for herself and her family. at home, she is mostly occupied with her children's homework. at work, she has no time allocated to herself due to the busyness of the trauma unit. she even works overtime during her rest days due to a shortage of staff, and to augment her income for her children's school fees. a lack of managerial support, demands from relatives, shortage of staff, shortage of equipment, and caring for complicated patients aggravate her stress. she started feeling numbness in the left-hand side of her body, and on consultation, she was diagnosed with hypertension, which could complicate to stroke. her blood pressure fluctuates and is elevated above the normal ranges. amlodipine, an antihypertensive drug, was prescribed for her hypertension. the doctor advised her that attending to her self-care and changing her lifestyle behaviour can have a significant influence in reducing her stress and normalising her blood pressure; to the extent of stopping amlodipine doses. sr joy decided to make an autonomous choice to take charge of her own life and to take care of herself by practising physical self-care activities such as walking, using the stairs, getting enough rest and sleep, and eating nutritious meals (autonomous choice, self-control, activity). she also started practising mindfulness and attending self-care wellness programmes to become knowledgeable about a healthy lifestyle (process). sr joy learned mindfulness practices which she applies every day when she experiences stressful situations in the icu. her relaxation technique includes booking herself into a massage parlour to relax her body, mind and spirit. she enjoys going out with colleagues and taking her kids out for movies (interaction). on sundays, she started attending church and joining the church choir. her ability to take care of herself physically, mentally, emotionally and socially enabled her to cope with her supervisory and shift-leading tasks in the busy icu. she was then able to gain a balance between work and home. she started losing weight and receiving compliments from colleagues about her appearance. this increased her confidence and self-esteem. her commitment, self-control and participation in self-care resulted in her signs of weakness and j o u r n a l p r e -p r o o f numbness disappearing and, on consultation, her blood pressure was in normal ranges. the doctor decided to stop the antihypertensive medication and encouraged her to continue with the self-care activities. a borderline case contains some, but not all, attributes of the concept being studied [13] . mr success is a 55-year-old professional nurse, working in a medical ward. he has developed diabetes mellitus and hypertension. his blood glucose levels require insulin injections on a daily basis, while his blood pressure requires dietary changes. he takes time off to attend to his clinic appointments, self-care educational programmes, and injects his insulin doses at the right times. the programmes teach him about controlling his nutrition, and he has reduced his sugar and salt intake as a result. he rarely exercises and does not attend church. on saturdays, he goes out partying with his friends, drinks alcohol and consumes fatty and salty foods. this results in his sugar levels and blood pressure going up and becoming uncontrollable. on mondays, he absents himself from work as he experiences dizzy spells and at times he gets admitted to hospital with increased sugar and blood pressure levels. sr jane is a 35-year-old professional nurse working in a general icu which admits ventilated patients diagnosed with hiv and confirmed covid-19 cases. she is obese, drinks alcohol and takes drugs to relieve her fears and stress that she might contract infections from her patients. she abuses scheduled drugs such as morphine. she does not want to take her rest days as this interferes with her accessibility to drugs at work. she seldom interacts with friends and other family members (interaction, self-control). she refuses to go for counselling, attend educational programmes (education) or drug and alcohol anonymous groups (autonomous choice). she does not engage in physical exercise and is continually buying fatty foods from restaurants (process, activity). she is now failing to perform her job as stated in her scope of practice (capability). she makes inexcusable errors when administering medication to patients, she is irritable and fights more often with colleagues and families. one patient had to be resuscitated after she gave an incorrect medication dose, and the staff and patients are complaining that she comes to work wearing dirty uniforms and smelling of alcohol. other staff members are refusing to work on her shift due to the increased number of patient safety incidences. antecedents are the necessary skills required before the occurrence of an event and eight are highlighted in this article: self-motivation, participation, commitment, resources, religious and cultural beliefs, social, spiritual and professional support, and availability of time [13] . self-motivation is the driving force within an individual to focus and accomplish self-care goals [33] . self-motivation encourages active participation and involvement in practising self-care activities such as mindfulness, nutrition and exercise. it promotes individuals joining prayer meetings, family celebrations and organisations in the community. professional nurses should be committed and be consistent in practising self-care activities. commitment and consistency result in the long-term personal and professional benefits of self-care. the mobilisation of the resources encompasses mindfulness, mentoring, supervision, selfcare education training, and life-skills training. examples of mindfulness techniques are mindful eating and meditation. life-skills training includes self-awareness, problem solving, and time management. the mobilisation of these resources benefits participants to gain an understanding of the effective self-care activities and become consistent in practising those activities [3, 34] . religious and cultural beliefs: in islam, self-care is regarded as the first part of caring. it is taught in their belief system as a moral imperative for everyone in the islamic community [5] . interacting with family members, friends and colleagues provide social, spiritual and professional support needed during self-care. the practise of self-care is about engaging in meaningful and non-toxic relationships. spiritual care activities enhance feelings of connectedness and may or may not be related to religion. teamwork and team-building activities at the workplace are encouraged to increase team spirit. social self-care activities define the relationships and interactions that are developed and maintained as personal and j o u r n a l p r e -p r o o f professional support systems. specific activities, such as spending time with friends, a spouse and family, can be performed to strengthen these relationships. socialising with friends was found to be both supportive and meaningful. spiritual self-care support can be achieved by spending time in a spiritual community, spending time in nature, meditating, attending worship, praying and engaging in other spiritual practices [34] [35] [36] . the availability of time is crucial when planning self-care activities. professional nurses are extremely busy in the icu, and if they fail to manage their time, they will not have enough time to take care of themselves. this is particularly true of them taking break times and the time to interact with family members, friends and colleagues. consequences are the outcomes of the manifestation of the concept [13] . the consequences of self-care can bring about the following benefits: maintenance of health and wellbeing, the ability to reach autonomy, increased self-esteem, disease prevention and empowerment, increased social support, and the ability to cope with stress. interacting with family, friends and other health professionals results in increased social support. the individual practising self-care develops increased self-esteem and confidence [37] . there will also be disease prevention through controlling risk factors, the promotion of health, preserving wholeness of character and continuing personal and professional growth [8, 15] . practising self-care results in long-term personal and professional benefits such as maintaining health and wellbeing, improving physical, social, spiritual and mental wellbeing, gaining the ability to reach autonomy, increased self-esteem, disease prevention and empowerment, increased social support, and the ability to cope with stress. the maintenance of health and wellbeing relates to preventing disease occurrence with self-care and being physically, mentally, psychologically and spiritually healthy. family involvement also plays a role in self-care in terms of increased social support. autonomy occurs when the professional nurse becomes independent and shows responsibility to self. the professional nurse takes charge of their own life by showing ownership of selfcare activities. this, in turn, enables them to be empowered. the individual practising self-care develops increased self-esteem and confidence [30] . disease prevention will occur by controlling risk factors, promoting health, preserving wholeness of character, and continuing with personal and professional growth [8, 15] . family members can also participate in the scheduled self-care activities. moreover, spending time with colleagues and participating in team-building increases team spirit. there will be peace in the workplace, increased job satisfaction and the ability to cope with stress. empirical referents denote categories of the actual phenomenon that demonstrate the occurrence of a concept [13] . concept analysis provides the foundation for further rigorous instruments of self-care, and the tool "exercise of self-care agency scale" can be used to measure self-care agency. the professional nurses' capabilities to initiate and perform selfcare is affected by the following attributes: age, gender, their preference in activities, their choices in life, educational levels, self-control and interactions with other people. the methods that can be used to develop self-care capabilities include motivation, participation, commitment, the availability of resources, social, professional, and spiritual support, and religious beliefs. attendance in self-care educational programmes, exercise programmes, and community events can also be used to measure the attributes of self-care [38] . the concept of 'self-care' is summarised as a process of practising activities to care for oneself to preserve one's own health without medical consultation. this process involves making an autonomous choice to improve one's health by interacting with other people and acquiring knowledge and skills through education to promote the physical, mental, emotional and spiritual being. through self-care educational talks, a professional nurse can learn more j o u r n a l p r e -p r o o f about health, health risks and lifestyle choices, such as a healthy diet and regular exercise [39] . the central concept of 'facilitation of self-care' contributes a lot to nursing practice, nursing education and nursing research. in nursing practice, the facilitation of self-care is significant as professional nurses experience stress, burnout and compassion fatigue when caring for critically ill patients. defining the concept will assist the professional nurses in practising what they preach, and prioritising their physical, emotional, social and spiritual wellbeing while caring for critically ill patients. this concept is also significant in nursing education to ensure that students understand the concept while they are still studying. the students will be able to correlate their theory in clinical practice, and this will assist them in taking care of themselves while caring for critically ill patients. more research should be conducted to further interview professional nurses regarding a developed model after the identification of the central concept 'facilitation of self-care'. the research could be based on the benefits of implementing the model that has been developed. the findings of this article indicated the importance of clarifying the definition of self-care to avoid misinterpretations, ambiguousness, and to encourage prioritisation in practising selfcare. this article described the seven attributes of the concept of self-care, namely the process, activity, capability, autonomous choice, education, self-control and interaction. seven antecedents were presented, including self-motivation, participation, commitment, resources, religious and cultural beliefs, social, spiritual and professional support, and the availability of time. the mentioned consequences include the maintenance of health and wellbeing, autonomy, increased self-esteem, disease prevention, empowerment, increased social support, and the ability to cope with stress. the model, contrary and borderline cases provided relevant examples to clarify the concept of self-care as it relates to the identified attributes, antecedents and consequences. the consequences reinforced that the concept of self-care is important in nursing practice. thus, registered nurses should focus on their own self-care before they teach and motivate their patients about the importance of this concept of self-care. this article highlighted the definition of the concept of self-care in relation to its attributes, antecedents, consequences and empirical referents. walker and avant's framework, which includes eight steps, was applied in the article [13] . a model case, borderline, related and contrary case were described in the form of scenarios. the implications and recommendations to nursing practice were also presented. nursing: concepts of practice world health organisation. health education of self-care: possibilities and limitations exploring the meaning and practice of self-care among palliative care nurses and doctors: a qualitative study practicing self-care for nurses: a nursing program initiative. ojin: the online j issues in 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future health care professionals: case report. occupational therapy faculty publications self-management of multiple chronic conditions by community-dwelling older adults: a concept analysis a concept analysis of self-management for cancer patients' homebased rehabilitation self-compassion is associated with less stress and depression and greater attention and brain response to affective stimuli in women managers self-compassion as self-care: a simple and effective tool for counsellor educators and counselling students self-compassion as a predictor of self-care: a study of social work clinicians self-care ability and self-compassion: the implication toward life satisfaction of the elderly factors associated with nurses' self-efficacy in clinical setting in iran concept analysis of self-regulation in health behavior the impact of self-monitoring in chronic illness on healthcare utilisation: a systematic review of reviews self-care of adolescents in the puerperal period: application of the orem theory an evolutionary analysis of the concept of self-care self-care concept analysis in cancer patients: an evolutionary concept analysis the motivation to stay motivated making self-care a priority: care for the carer the role of self-care and hardiness in moderating burnout in mental health counsellors effectiveness of self-care in reducing symptoms of secondary traumatic stress. social work master's clinic research papers what do we mean by "older adults' persistent pain self-management"? a concept analysis promoting self-care abilities of patients: nurses'roles occupational stress and the importance of self-care and resilence: focus on veterinary nursing the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord-316690-s8jtv4an authors: xiong, huan; yi, shuanglian; lin, yufen title: the psychological status and self-efficacy of nurses during covid-19 outbreak: a cross-sectional survey date: 2020-09-08 journal: inquiry doi: 10.1177/0046958020957114 sha: doc_id: 316690 cord_uid: s8jtv4an a novel coronavirus pneumonia broke out and gradually developed into a global public health problem. health care workers, especially nurses, suffered from great occupational pressure and psychological distress during the outbreak of infectious diseases. we performed a cross-sectional survey to investigate the psychological status and self-efficacy of nurses in public hospital during covid-19 outbreak between 16th and 25th february 2020. a total of 223 nurses participated in this study. the prevalence of anxiety and depression symptoms was 40.8% (ci 95%: 34.4%-47.2%) and 26.4% (ci 95%: 20.6%-42.2%), respectively. there was no difference in the prevalence of anxiety symptoms among demographic variables. there was significant differences in the prevalence of depression symptoms according to professional titles (p = .020). the mean score of self-efficacy was 25.90 ± 7.55. the self-efficacy was negatively correlated with anxiety (r = −0.161, p < .05). the psychological status of nurses in public hospital during covid-19 outbreak needs our attention. improving nurses’ self-efficacy in dealing with emerging infectious diseases may be helpful to their psychology. in december 2019, a novel coronavirus pneumonia case was reported in wuhan, china, and then the novel coronavirus (covid-19) broke out in china rapidly and spread to other countries. the novel coronavirus pneumonia soon attracted international concern and was listed as a public health emergencies by who. 1 the novel coronavirus pneumonia was confirmed to be a human-to-human disease, and the main source of transmission was symptomatic diagnosed patients. 2 moreover, it was reported that asymptomatic carriers may also transfer the covid-19 to others. 3 on february 25th, 78064 confirmed cases and 2715 deaths cases have been reported in mainland china. 4 as a result, the general public were likely to be stressed anxious and depressed during the outbreak and at the peak of the covid-19 epidemic. 5, 6 during the outbreak of covid-19, medical staff in public hospital, especially nurses, provide health service for patients as usual. the patients they contact may be those being in incubation period, waiting to be diagnosed, or asymptomatic carriers. they are exposed to many known and unknown risk factors. as of february 11th, 3019 medical staff were infected inquiry with covid-19 in mainland china, resulting in 5 death. 7 coping with infectious diseases, the medical staff were under great occupational pressure and experienced psychological distress. 6 little is known about psychological status of nurses during covid-19 outbreak. health care workers suffered from great stress and psychological distress during the epidemic of infectious diseases. for example, health care workers reported disease related concern and suffered from somatic symptoms and psychological distress during sars attack. 7, 8 middle east respiratory syndrome coronavirus caused worry, fear and ptsd-like symptoms among hospital workers. 9,10 a significant proportion of health care workers experienced worry and anxiety about influenza pandemic. 11 due to reduced accessibility to psychological support, less first-hand medical information, less intensive training on personal protective equipment and infection control measures during covid-19 pandemic, health care workers were more likely to experience stress and psychological distress. 8 a multinational, multicentre study showed that out of 906 health care workers who participated in the survey during covid-19 pandemic suffered from expansive range of physical symptoms, 5.3% was moderate to very-severe depression, and 8.7% was moderate to extremely-severe anxiety. 9 these psychological distress caused by acute infectious diseases may persist for a long time and even lead to posttraumatic stress disorder. 10, 11 compared with other hospital staff, nurses had a high proportion of psychological distress. 12 what's more, a study found that non-frontline nurses who worked in hospitals were more likely to suffer from psychological problems than front-line nurses. 13 therefore, we intended to investigate the psychological status of these nurses. self-efficacy reflects a belief and a sense of confidence in whether individuals can use their capacity to achieve tasks. 14 the self-efficacy is related to the level of motivation, actions, and psychological state. 15 schwarzer raised the concept of general self-efficacy, which referring to an individual's overall self-confidence in dealing with challenges of different environments contexts or burgeoning issues. 16 it can reflect individual's behavior and psychological status in different contexts. the self-efficacy of nurses correlated with mental health, resilience, and job burnout. [17] [18] [19] studies found there was a negative correlation between general self-efficacy and anxiety. 20, 21 during the outbreak of sars, health care workers with low self-efficacy experienced higher fear. 22 in addition, self-efficacy was a important factor in predicting nurses' willingness to care for patients with emerging infectious disease. 23, 24 this study was to examine the psychological status and self-efficacy of nurses still working in public hospital during covid-19 outbreak, and explore the relationships among demographic variables, anxiety, depression, and self-efficacy. this study was a descriptive cross-sectional survey. the participants were from one of public tertiary hospitals in xiamen, fujian province. this hospital is not responsible for the treatment of covid-19, but it also admits fever and suspected patients. once the patients are confirmed to be infected with covid-19, they will be sent to another government designated hospital for treatment. respondents was limited to registered nurses still working in the hospital during the outbreak of covid-19. we searched the departments admitting patients as usual in the hospital's electronic medical record system. then we explained the survey to the head nurses of each department and obtain their consent. we sent recruitment and the internet questionnaire to the head nurses every day, and they helped us to transmit questionnaires to nurses. nurses choose whether to participate in the survey according to their own willingness. when no one participated in the survey for 3 days, we terminated the questionnaire. the survey was granted by the medical ethics committee of hospital (xmzsyyky ethics no. 2020-006). data were collected between 16th and 25th february 2020, and a total of 223 nurses participated in the study. demographic characteristics. the nurses' demographic characteristics in this study include gender, age, education level, professional titles, working experience, department, living status, the history of contact with confirmed, suspected or fever patient. the generalized anxiety disorder-7 (gad-7). spitzer developed a 7-item self-report instrument based on the dsm-iv criteria for screening generalized anxiety disorder. 25 it asked participants how often they were bothered by some typical anxiety symptoms during the last 2 weeks. each item is scored from 0 to 3. when the total score is more than 5 points, it indicates that respondents may experience anxiety symptoms. gad-7 had good reliability and validity in chinese population. 26 the chinese version of the patient health questionnaire (phq-9). the phq-9 was developed by kroenke et al based on the dsm-iv criteria, and it was to assess the severity of depression. 27 the phq-9 consists of 9 items, with a total score ranging from 0 to 27. respondents whose score is over 5 points may have different degrees of depression symptoms or even depression disorder. this scale is brief and convenient, and it has excellent internal consistency reliability and test-retest reliability. the cronbach's α of the chinese version of phq-9 in the general population was 0.86, test-retest reliability coefficient was 0.86. 28 self-efficacy. we used the chinese version of the general self-efficacy scale to measure the confidence and belief of nurses when facing to covid-19. the scale includes 10 items, ranging from 1 to 4. the higher scores indicate having greater confidence and self-efficacy in coping challenges and stress. the cronbach's α coefficient, test-retest reliability coefficient, and split-half reliability were 0.87, 0.83 and 0.82, respectively. 29 data analysis. all the data were analyzed using spss22.0. demographic information, and scores of anxiety, depression, and self-efficacy were described by number (n), percentage (%), mean and standard deviation. the relationship between anxiety, depression, and demographic variables were examined by chi-square test or fisher exact tests. to explore the relationship between anxiety, depression, and self-efficacy, we used pearson correlation analysis. a total of 361 nurses from 11 departments met our inclusion exclusion criteria, and finally 231 nurses participated in the study. the response rate was 61.8%. the majority of the participants were female (97.3%), between 26 and 45 years old (71.7%), and had baccalaureate degree. almost half of the nurses had primary professional titles and less than 10 years of working experience. fifty-nine nurses contacted with confirmed or suspected patients during outbreak, and 67.7% of nurses contacted with fever patients. other demographic information is shown in table 1 . the mean score of gad-7 was 4.31 ± 4.52, and phq-9 was 3.24 ± 4.04 (table 3) . table 2 shows the prevalence of anxiety and depression among nurses. the prevalence of anxiety and depression symptoms was 40.8% (ci 95%: 34.4%-47.2%) and 26.4% (ci 95%: 20.6%-42.2%), respectively. ninety one nurses experienced different degree of anxiety whose gad-7 scores were more than 5 points, including 64 mild anxiety, 19 moderate anxiety and 8 severe anxiety. a total of 59 nurses had depressive symptoms, and the proportion of mild, moderate, severe, and extremely severe depression was 74.6%, 18.6%, 5.1%, and 1.7%. there was no difference in the prevalence of anxiety symptoms in demographic variables. there was significant differences in the prevalence of depression symptoms according to professional titles (p = .020) (see table 1 ). the mean score of self-efficacy was 25.90 ± 7.55. and as shown in table 3 , the nurses' self-efficacy was negatively correlated with anxiety (r = −0.161, p < .05). there was no significant correlation between self-efficacy and depression (r = −0.104, p > 0.05). this survey was to investigate psychological status and self-efficacy of nurses in public hospital, still caring for patients during covid-19 outbreak. we found the prevalence of anxiety and depression symptoms among nurses was 40.8% and 26.4%, respectively, which was higher than other similar studies on health care workers and non-healthcare workers. 8, 9 possible explanation may be that china was the first country facing a large-scale outbreak of covid-19, health care workers suffered from great physical and psychological stress. according to other study, it was reported nurses in one of designated hospital were under great psychological stress and experienced psychological symptoms, such as compulsion, anxiety, fear, etc. 30 we found the prevalence of anxiety symptoms among nurses was 40.8%, and depression was 26.4%. although this hospital is not government designated hospital, the results indicate that nurses have high levels of anxiety and depression. this hospital it admits fever patients and patients waiting to be diagnosed. nurses in this hospital are also at high risk of exposure to the virus. unlike nurses in designated hospital who are certain about the patients' diagnoses and wear a full set of protective equipments, they may have come across newly admitted patients without signs and symptoms to indicate whether they had infected covid-19 and they may not have taken effective protective measures. in our study, the incidence of moderate and severe anxiety was 12.1%, and depression was 6.7%, which was lower than reported general population. 5 similarly, a study found that the general public had higher level of vicarious traumatization than the front-line nurses. 13 this may be related to the prolonged lockdown affecting daily life and poor disease knowledge. 6, 13 these results imply that nurses in this type of hospital have great psychological distress during outbreak. it suggests that managers should pay attention to nurses' psychological status and provide support to relieve their anxiety and depression. in this study, nurses with intermediate professional titles have higher prevalence of depression symptoms. a possible explanation is that nurses with intermediate titles are wellexperienced. they are an important part of the battle of epidemic prevention and control, and they can evaluate the risk of infection according to clinical experience. as a result, they may have greater psychological distress. we also found that there was no difference in the prevalence of anxiety symptoms among demographic variables. it may be that anxiety symptoms are widespread among nurses during covid-19 outbreak. it needs to be further verified. the mean score of self-efficacy was 25.90 ± 7.55, which was lower than previous studies. 31, 32 possible reasons may be due to the fact that covid-19 is a novel coronavirus and causes an outbreak in a short time. nurses lack experience and confidence to cope with it. the results demonstrated that self-efficacy was negatively correlated with anxiety (r = −0.161, p < .05), which was consistent with previous studies. 33 nurses who were not confident in coping with the covid-19 may feel more anxious. covid-19 is a new coronavirus, and it causes a rapid outbreak of disease. medical staff need to learn the knowledge of novel coronavirus pneumonia and adjust therapeutic plan continuously. some nurses feel their knowledge is insufficient, which makes nurses feel incompetent and results in negative psychological experience. 34 this can provide a reference for the training of nurses' emergency ability in the future. different from previous studies, there was no significant correlation between self-efficacy and depression. 33 this may be due to the difference in population and situations. in order to better respond to outbreaks and avoid psychological crisis on population, the chinese government has taken a series of psychological assistance intervention, including releasing guiding principles for psychological intervention during covid-19, publishing psychological guidelines books, creating psychological assistance hotlines, and providing online psychological counseling. 35 however, according to guidelines issued by the central health authority, the first targets of psychological intervention are confirmed patients, frontline health professionals and administrative staff. 36 this study found the nurse in this hospital had high incidence of anxiety and depression, and there was no significant difference in the incidence of anxiety and depression among departments and whether exposed to confirmed patients or not. these indicated that the psychological status of nurses who worked in non designed hospital or who didn't contact with confirmed patients during outbreak also needs attention and support. online psychological self-help intervention system, 37 like online cognitive behavioral therapy and mindfulness-based interventions, may be helpful to promote nurses' mental health. cognitive behavioral therapy may challenge cognitive bias when they overestimate the risk of contracting and suffering from covid-19, and enhance confidence in the ability to take care of patients. 6, 38 mindfulness-based interventions is aimed at reducing stress through mindfulness meditation practices. 39 they have demonstrated efficacy in reducing depression and anxiety symptoms among university students during the epidemic of covid-19. 40 there were some limitations in this study. first, we only sent recruitment to nurses in 1 hospital, so this study failed to compare the differences among hospitals and groups of people, such as doctors, technician, administrative staff, etc. thus, the findings should be further confirmed in different hospital and different health care workers. second, this research lasted for 10 days, and a total of 223 nurses took part in it ultimately. response bias may exist and sample size may affect data analysis results. sample size needs to be expanded in the future. third, this study was a cross-sectional survey, lacking followup, and the questionnaires were self-report. there were likely to lead to recall and reporting bias. moreover, we couldn't distinguish if the anxiety or depression was caused by the covid-19 or preexisting, and lacked follow-up care for nurses who had severe anxiety or depression. in conclusion, our results show that nurses in non government designated hospital have great prevalence of anxiety and depression symptoms during covid-19 outbreak. nurses' professional titles are related to depression. nurses with intermediate professional titles experience more depression symptoms. the self-efficacy coping to covid-19 was negatively correlated with anxiety. table 3 . correlation analysis of anxiety, depression, and self-efficacy. phq-9 self-efficacy gad-7 1 phq-9 0.689** 1 self-efficacy −0.161* −0.104 1 *p < .05. **p < .01. world health organization. novel coronavirus (2019-ncov) situation report a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster presumed asymptomatic carrier transmission of covid-19 up to 24 february 25th novel coronavirus 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potential conflicts of interest with respect to the research, authorship, and/or publication of this article. key: cord-024921-rcpdrpo7 authors: kim, nam kyoon n.; parker, simon c. title: entrepreneurial homeworkers date: 2020-05-18 journal: small bus econ doi: 10.1007/s11187-020-00356-6 sha: doc_id: 24921 cord_uid: rcpdrpo7 nearly 40% of british self-employees are homeworkers. using a large representative sample of the uk longitudinal survey data, we explore the determinants of self-employed homeworking, distinguishing between genders. we reject the notion that homeworking is a transitional entrepreneurial state that the self-employed “grow out of”, while establishing that both employer status and business structure play an important role in predicting which self-employed become homeworkers. our findings also shed light on two outstanding puzzles in entrepreneurship scholarship: why so few of the self-employed create jobs for others, and why on average the self-employed suffer an earnings penalty compared with employees. the regional entrepreneurship literature continues to grow rapidly, reflecting enduring interest in understanding entrepreneurs' venture location choices and the resulting implications for regional economic development. recent research has analyzed, inter alia: the determinants of persistent differences in regional rates of entrepreneurship (andersson and koster 2010; bishop and shilcof 2017; fotopoulos and storey 2017; koster and hans 2017; modrego et al. 2017) ; regional firm entry and exit rates (bishop and shilcof 2017; li 2017) ; the location and mobility of entrepreneurs (di addario and vuri 2010; kulchina 2016); regional knowledge spillovers as an entrepreneurship attractor (audretsch et al. 2006; bonaccorsi et al. 2014) ; and the concentration of entrepreneurship in neighborhoods, cities and clusters (di addario and vuri 2010; pe'er and keil 2013) . this valuable background has greatly enhanced our understanding of regional aspects of entrepreneurship. what is much less well-known is why many entrepreneurs locate their ventures at their place of residence. it turns out that entrepreneurial homeworkers are surprisingly prevalent. for example, according to the present study, which utilizes data from the british household panel survey (bhps)-a representative longitudinal dataset of individuals and households residing in the uk-nearly 40% of the self-employed in the uk are homeworkers. this fact appears to be little known, in part because apart from a handful of prior studies (mason et al. 2011; reuschke 2016) , entrepreneurial homeworking has been largely neglected as a research topic. this neglect is surprising for several reasons. first, homeworking influences entrepreneurs' ability to serve lucrative markets and scale their businesses by hiring workers. hence, it bears on entrepreneurial performance. second, homeworking carries implications for understanding who participates in entrepreneurship. this is of interest to researchers concerned with the drivers of entrepreneurial selection. third, the joint emergence of high-tech occupations and the decline of "traditional" employment provided by large employers make homeworking a topical alternative mode of employment. there is considerable policy interest in discovering more about the prevalence of homeworking in the new digital economy (blount 2015; huws et al. 2018) . moreover, uncovering the determinants of entrepreneurial homeworking can inform several prominent areas of entrepreneurship research. these include how entrepreneurs manage work-life balance, where they locate their ventures, and how public policy influences entry into entrepreneurship. first, emerging research demonstrates that many people value the flexibility of being self-employed, and often "blur" home and work commitments to enhance their well-being and satisfaction (boden 1999; hurst and pugsley 2011; sevä et al. 2016) . while much research has emphasized the importance of variations in work hours for achieving flexibility, the potential role of homeworking in this regard (whereby entrepreneurs can quickly switch between performing home and work duties) has been rather neglected. second, entrepreneurship scholars are increasingly investigating entrepreneurs' venture location choices (dahl and sorenson 2010; koster and venhorst 2014; kulchina 2016; stam 2007) , and how these choices affect the performance of their ventures (di addario and vuri 2010; frederiksen et al. 2016 ). yet this body of research is largely silent about homeworking, even though it may allow entrepreneurs to economize on commuting costs and rents, while facilitating flexible working. third, public policy is known to favor entrepreneurship through, for example, various programs that promote self-employment as a career choice (caliendo and kritikos 2010; michaelides and benus 2012; parker 2018, chaps. 18-21) . policymakers also design policies to encourage entrepreneurs to create jobs for others (henrekson and johansson 2010; mathur 2010) . to date, however, few policy prescriptions have connected these hitherto disparate threads, even though (as we will argue) entrepreneurial homeworking may provide a basis for doing so. might entrepreneurial homeworking have been neglected because it is merely a transitional state, which entrepreneurs use temporarily before scaling up and professionalizing their ventures? the purpose of the present article is to investigate this possibility, and in the process to analyze the determinants of homeworking, including business structure and caregiving responsibilities. using bhps data, this paper uncovers salient determinants of selection into homeworking and provides evidence about whether homeworking is or is not a transitional phase for entrepreneurial ventures. as a byproduct, our findings also shed light on two outstanding puzzles in entrepreneurship scholarship, showing how homeworking can partly explain why so few of the self-employed create jobs for others, and why on average the self-employed suffer an earnings penalty compared with employees. our primary research question asks: "is homeworking a transitional state, which entrepreneurs use to get started before scaling up and professionalizing their business?" in addressing this question, one needs to determine what factors influence entrepreneurs' decision to work at home rather than in a separate, dedicated workplace. to that end, we draw on a broad body of literature relating to occupational choice models that analyze the decisions of individuals about whether to become entrepreneurs. the "background literature" section will first briefly review background literature on entrepreneurship as an occupational choice, and key factors associated with entrepreneurial homeworking. the "factors influencing homeworking" section then develops several hypotheses which apply occupational choice-based logic to the entrepreneurial homeworking setting: the goal is to identify factors that influence entrepreneurial homeworking. the "is homeworking a transitional state?" section then explores factors associated with entrepreneurs using homeworking as a transitional state. the reason for this ordering of the conceptual discussion is that influencing factors need to be considered before the implications of transitioning out of being an entrepreneurial homeworker can be understood. occupational choice models of entrepreneurship analyze the decisions of individuals who have heterogeneous tastes and abilities and decide whether to become entrepreneurs or employees. individuals derive utility from both financial factors like profits and non-financial factors such as autonomy (taylor 1996) or job satisfaction (guerra and patuelli 2016) . individuals compare the utility they expect to derive from entrepreneurship with that obtainable from their next best alternative, which is usually taken to be wage employment (parker 2018, chap. 2) . some occupational choice models focus only on utility derived from financial returns (e.g., evans and jovanovic 1989; kihlstrom and laffont 1979) . they recognize that individuals choose not only whether to become an entrepreneur but also how many factors of production to utilize, e.g., capital and/or labor. for example, kihlstrom and laffont (1979) jointly analyzed the decision to become an entrepreneur with the choice of how many workers to employ, in a model where individuals differ from each other in terms of their risk tolerance. entrepreneurship is widely recognized as a risky occupation: kihlstrom and laffont (1979) demonstrated that the most risk-tolerant people are both more likely to become entrepreneurs and to hire workers. other models introduce non-financial considerations into the mix. evidence shows that non-financial factors influence entrepreneurs' choices (burke et al. 2000; hurst and pugsley 2011; taylor 1996) . these factors include a desire for creativity and autonomy (block and koellinger 2009; hytti et al. 2013; schneck 2014) , and intrinsic satisfaction from work (guerra and patuelli 2016; lange 2012) . another relevant factor is the flexibility afforded by self-employment. entrepreneurs work longer hours on average than employees but often enjoy greater latitude over when they work and what tasks they perform there (hyytinen and ruuskanen 2007) . flexibility can be especially beneficial for entrepreneurs having household and caregiving responsibilities, who need to juggle their time between work and home (boden 1999; hurst and pugsley 2011; sevä et al. 2016) . overall, the evidence suggests that entrepreneurs care about both financial payoffs and non-financial factors when deciding whether to run a business (block and koellinger 2009 ). this insight informs our theorizing below, which incorporates both financial and nonfinancial components of utility into entrepreneurs' decision-making calculus. other research has recognized that the occupational choice of entrepreneurship does not take place in a spatial vacuum. several reasons explain why many entrepreneurs prefer to situate their ventures close to, or at, their homes. this may be where their customer base and other stakeholders are located (stam 2007) . the local nature of social networks and the need to reduce commuting costs given long work hours also explain why many entrepreneurs live close to where they work. locating a venture far from home risks weakening the effectiveness of social capital. in addition, the entrepreneur may want to work close to dependents who need their care and support. relatively few studies to date have examined entrepreneurial homeworking. two important exceptions are mason et al. (2011) and reuschke (2016) . mason et al. (2011) provide a descriptive analysis of home-based small-and medium-sized businesses in the uk, emphasizing the regional aspects of such businesses. mason et al. (2011) dismiss as inaccurate the stereotype that home-based ventures are part-time, small and marginal. instead, "the majority of home-based businesses are serious undertakings, occupying their own dedicated space, operating on a full-time basis, and based at home largely for business rather than for lifestyle reasons... these findings challenge the simplistic stereotype that dismisses home-based businesses as part-time, small and marginal and, therefore, of little economic significance" (mason et al. 2011, p. 634) . mason et al. (2011) build on earlier work which looked exclusively at women home-based business owners (jurik 1998; loscocco and smith-hunter 2004) . reuschke (2016) in contrast used the british household panel survey (bhps) data to explore how housing characteristics affect entries into self-employment separately for homeworkers and non-homeworkers. reuschke (2016) proposed that housing influences differently entry into homeworking versus nonhomeworking. she pointed out that housing provides not only financial benefits as a source of collateral to relieve borrowing constraints but also an affordable and versatile space in which to work flexibly-a precondition for many people such as those with caregiving responsibilities. below, we will focus on three major potential influences on entrepreneurial homeworking: employing others, forming business partnerships, and discharging caregiving responsibilities. we commence by noting that many residences are spatially constrained and lack the facilities to accommodate employees on-site (reuschke 2016) . this may prevent entrepreneurs from being able to offer a comfortable working environment to employees, inducing entrepreneurs to eschew homeworking in favor of using a dedicated office or factory location outside the home. in addition, many employees expect standard working conditions and hours, and access to standard office resources which may be lacking in somebody else's home. for instance, unless a home is exceptionally commodious, and can be renovated to house regular office facilities and equipment, it may be difficult to offer employees the kinds of working conditions they are used to in larger firms. in response, a home-based entrepreneur might be willing for employees to work remotely, e.g., at clients' premises. but remoteness raises the risk of agency costs arising from moral hazard: it may be difficult for the entrepreneur to monitor and supervise workers and prevent them from slacking (demsetz 1983; jensen and meckling 1976) . one solution to this problem is for the entrepreneur to rent a central, dedicated office location, which is the logical alternative to homeworking. in such a location, the entrepreneur can work alongside their employees, making monitoring simpler and more effective. for all these reasons, one would therefore expect that, in the context of maximizing expected financial returns, employer entrepreneurs are less likely to be homeworkers: hypothesis 1 the propensities of entrepreneurs to choose homeworking and hire employees are negatively related. setting up a venture from home may entail another drawback too: it can be harder for entrepreneurs to work together with other business partners and operate more financially ambitious enterprises. in general, business partners tend not to be residentially co-located, and they are rarely selected on that basis. non-co-located partners of a home-based business must therefore choose which partner's home the business will be situated at. home location is likely to impose monitoring costs on the business partner whose residence is not being used as the business location, as discussed above in the context of employees. while this is not necessarily an insuperable complication, it can entail time-consuming and ongoing negotiations between business partners, reducing the attractiveness of home-based venturing for one or more of the business partners. for these reasons, one might expect homeworking to be better suited to sole proprietorships than to business partnerships. there is also likely to be a gender dimension to this issue. evidence shows that a smaller proportion of women than men incorporate their businesses using legal forms like business partnerships relative to sole proprietorships (brush 1992; klapper and parker 2010) . there are many reasons for this, reflecting in part the pronounced concentration of women in businesses involving part-time work and located in industry sectors with limited opportunities for growth (parker 2018, chap. 8) . usually, only larger-scale ventures can justify and support multiple business partners, and these tend to be operated more by men than women. we summarize these arguments as follows: hypothesis 2a the propensities of entrepreneurs to choose homeworking and form their businesses as partnerships are negatively related. hypothesis 2b the negative relationship between homeworking and business partnerships is stronger for men than for women entrepreneurs. another factor that bears on the homeworking choice relates to caregiving responsibilities. if externally provided childcare or eldercare is costly, homeworking might be attractive to entrepreneurs by offering them a flexible way to combine work and domestically provided caregiving (hyytinen and ruuskanen 2007) . many entrepreneurs have pressing commitments relating to the home, including caregiving responsibilities which can make working away from home problematic or onerous (craig et al. 2012; edwards and field-hendrey 2002) . for instance, evidence shows that household members-especially women-who look after disabled people, or who have young children, are more likely to be self-employed (craig et al. 2012; rønsen 2014; wellington 2001) . homeworking economizes on commuting costs, which is relevant to caregivers who must attend to the recurring needs of others, especially in cases where the caregiver has to devote regular periods of personal care. since children and disabled relatives are often located in or near the caregiver's home (sit et al. 2004) , homeworking can reduce these costs. given the wellknown flexibility of self-employment as a way of juggling work and life responsibilities (gimenez-nadal et al. 2012; thébaud 2015) , these arguments suggest that entrepreneurs with caregiving responsibilities find homeworking an especially attractive option to maximize the flexibility of entrepreneurship. in the literature to date, the potential for homeworking to help entrepreneurs juggle business and caregiving responsibilities has been explored principally for women entrepreneurs specifically, since women devote more time on average to caregiving responsibilities than men do (craig et al. 2012; edwards and field-hendrey 2002) . according to carr (1996) , 20% of self-employed women worked from home, compared with just 6% of self-employed men. craig et al. (2012) analyzed australian time use survey data and estimated that working from home is highly correlated with self-employment among mothers, who used selfemployment to combine earnings and childcare, whereas fathers prioritized paid employment. it is important at this juncture to distinguish between two different loci of choice for entrepreneurs who want to combine business and caregiving activities. one locus of choice is between entrepreneurship versus paid employment-the occupational choice discussed above. the other is between homeworking and nonhomeworking conditional on being an entrepreneur. it is possible that homeworking provides the most convenient way of juggling business and caregiving duties. however, it is also possible that self-employment provides entrepreneurs with enough flexibility that they can discharge their caregiving duties without having to locate their venture at home as well. nevertheless, we state the following hypotheses: hypothesis 3a the propensity of entrepreneurs to choose homeworking is positively associated with their caregiving responsibilities. hypothesis 3b the positive relationship between homeworking and caregiving is stronger for women than for men entrepreneurs. below, we discuss how hiring employees and forming business partnerships might only occur once the entrepreneur has ceased homeworking, and works from a separate, dedicated, location. throughout, the theoretical discussion draws on the literature introduced in the preceding subsections, extending its logic to the question at hand. as noted in the "background literature" section, entrepreneurship is risky. in response, entrants may craft riskminimization strategies. according to folta et al. (2010) , "hybrid" entrepreneurship is one such strategy, whereby employees continue working in their main job in paid employment while "dipping a toe" in the entrepreneurial waters to see if it is worth making a full-time transition. real options logic (dixit et al. 1994) suggests that entrants seek to avoid heavy early-stage investments until they are sure that the payoff in entrepreneurship is high enough to merit them. one such costly investment is in arranging to secure and equip an office location for a new venture, since if the venture fails to thrive, the associated costs are largely sunk and unrecoverable. in contrast, homeworking is cheap and involves little cost in setting up. real options logic then predicts that only if hybrid entrepreneurs generate sufficiently high returns will they choose to go fulltime. at that point, it makes sense to sink investments, including arranging office facilities. in contrast, this logic does not apply to non-hybrid entrants who switch completely into full-time entrepreneurship. these entrants may have different motives: e.g., they may have quit their job; are risk-neutral or risk-loving; prefer to work full-time on their venture; or start non-capital-intensive firms. such people may still benefit from homeworking, as discussed below; but the motive of choosing homeworking as a riskminimization strategy would be weak or absent. thus, if homeworking is a temporary, transitional arrangement, we would expect to see relatively high annual inflows of hybrid entrepreneurs into homeworking. in terms of outflows, if homeworking is a temporary solution for early-stage ventures, some of these ventures should shift to become non-homeworking businesses as they scale and professionalize. scaling often entails hiring employees (delmar et al. 2003 )-so, for the reasons given in the lead up to hypothesis 1, a homebased location may become unsuitable for new employees. that may require home-based solo entrepreneurs to quit homeworking and move the business into a conventional workspace instead. similar arguments apply to business partnerships: one might expect entrepreneurs who are professionalizing their ventures and taking on additional managerial and investment capacity embodied in another partner to replace homeworking with non-homeworking to facilitate that transition (see hypothesis 2). summarizing these predictions, we have: homeworking status in entrepreneurship is positively associated with transitions into non-homeworking employer status in entrepreneurship the following year. hypothesis 4b homeworking status in entrepreneurship is positively associated with transitions into non-homeworking business partnership status in entrepreneurship the following year. data come from the british household panel survey (bhps), an annual, nationally representative uk-wide household survey for social and economic research first administered in 1991 (buck et al. 2006 ). the first cohort consisted of 10,300 individuals across great britain. since 2001, respondents have been drawn from across the whole of the uk, i.e., great britain plus northern ireland. members of the original households were followed up with many participants agreeing to be reinterviewed in subsequent years. the bhps is wellsuited to analyzing homeworkers as it contains rich data on the self-employed, homeworking, and other salient variables discussed above. for most of the analysis that follows, we draw panel data from 2004 to 2008, the last 5 years the bhps was conducted. the sample frame in this study is all members of the great britain (england, scotland, and wales) workforce aged 16 years of age and over, who are either employed or self-employed. observations from northern ireland were excluded owing to data limitations. individuals who declared themselves retired, the longterm sick and disabled, and students were also excluded from the sample. although data on employees will be used to provide some subsequent checks on the results, the main results will focus only on the self-employed sample and the homeworking subsample. no upper age limit on the self-employed was imposed, as a non-trivial proportion (5.5%) of our self-employed sample are aged 65 and over. however, while subcontractors are coded as self-employed individuals in bhps dataset, they are closer to employees on contract. therefore, following reuschke (2016) , we removed subcontractors from our sample. entrepreneurial homeworkers prior researchers have measured homeworking in the entrepreneurial context as cases "where the work (production or service) occurs in the home, and those where the work occurs away from the home with the home serving as the administrative base... [the entrepreneurs are engaged in] selling products or services into the market operated by a selfemployed person, with or without employees, that uses residential property as a base from which the operation is run" (mason et al. 2011, p. 629) . consistent with this definition, "those self-employed workers who work at home or from their own home are considered as homebased businesses" (reuschke 2016, p. 384) . in the following, we will define a homeworker entrepreneur, homeworker, in precisely the same way as just described. indeed, the bhps codebook defines selfemployed homeworkers as "those who work principally at or from home." the other possible work locations are working from separate business premises; working from customer or client premises; or working at some other place such as a van or a stall. these are all nonhomeworkers. for example, a self-employed accountant could choose to sell their services from home using a phone and personal computer: they would be classified as a homeworker. alternatively, the same accountant may prefer to rent office space close to their clients, interacting with them there: they would not be classified as a homeworker. while self-employment is a widely used measure of entrepreneurship (parker 2018, sec. 1.3) , it is not without its limitations. self-employment can encompass individuals who are unlikely to be entrepreneurs by other criteria, such as innovation or novelty. it also omits many nascent entrepreneurs, who have not yet changed their labor market status to self-employed (parker and belghitar 2006) . on the other hand, almost all selfemployment involves the entrepreneurial functions of risk-bearing and business ownership and control. selfemployment is a prominent and important segment of the labor market, accounting for over 10% of the workforce in the uk, the usa, and many other countries (parker 2018, chap. 1) . many self-employed are business owners whose activities have been linked to aggregate productivity, wealth creation, job generation, innovation, and growth (guiso and schivardi 2011; koellinger and thurik 2012) . since all entrepreneurs own their own business and do not have an employer, the self-employment measure possesses the merit of inclusiveness. another advantage is that selfemployment data are also widely available in household surveys, which facilitates the analysis of homeworking. there are 4696 self-employed observations in our bhps sample, yielding a self-employment rate of 12.4%. of these, 36.9% (i.e., 1734 cases) are homeworkers. this fraction exceeded 40% in the final wave of the bhps (2008). in contrast, less than 2% of employees in the bhps sample work from home. employee homeworkers are not the central focus of this paper; some descriptive analysis later demonstrates that they are not comparable to self-employed homeworkers in several important respects and probably merit a separate empirical (as well as theoretical) treatment. the main independent variables operationalize the constructs introduced in hypotheses 1-3. they are measured as follows. first, the variable employer is coded as 1 for self-employed individuals who employ others, and 0 for self-employed individuals who work alone. second, we code a dummy variable business partnership for whether the respondent has one or more business partners in terms of the legal ownership of business. third, we measured caregiving with two dummy variables-caregiver (disabled), and caregiver (child). caregiver (disabled) equals 1 if the respondent looks after a disabled person, and 0 otherwise. likewise, caregiver (child) equals 1 if the respondent looks after a child under age 16, and 0 otherwise. fourth, since some of the hypotheses distinguish between males and females, we coded the variable female to equal one if the respondent is female and zero if they are male. finally, we measured hybrid entrepreneur with a dummy variable which equals 1 if the respondent's main job is a paid employment with a self-employment second job, and 0 if the respondent is self-employed but does not have a second job. this follows the definition of hybrid entrepreneur by folta et al. (2010) , which is defined as "individuals who engage in selfemployment activity while simultaneously holding a primary job in wage work" (p 254). we included numerous control variables in our empirical analysis to reduce the risk of omitted variable bias. we briefly outline these together with a rationale for their inclusion. first, it has been suggested that technological change has made operating home-based businesses more feasible than it used to be. entrepreneurs who work in high-tech occupations (e.g., r&d or legal services) may find it easier to connect remotely with customers and suppliers and so operate their business effectively from home. we coded a variable hightech occupation as a binary variable using the bhps soc 2000 classification. science, technology, research, design, legal, and financial professions are coded as high-tech occupations. table 7 in the appendix provides a detailed list. second, demographic variables may also affect homeworking. for example, married entrepreneurs may be more financially secure and so better able to support flexible homeworking that can accommodate other household responsibilities such as caregiving (werbel and danes 2010) . we accordingly coded a dummy variable called married. in addition, abundant research has linked human capital with self-employment, which may affect various types of selfemployment differently (parker 2018, sec. 5 .2). we therefore included two human capital controls: a dummy for whether the respondent is a graduate, graduate; and age as a broad measure of experience, age. and, since homeworking may be the only way that individuals in poor health can operate a business, we also added a control variable health limits work. third, social capital may be linked to homeworking to the extent that a home-based business leverages local social networks and resources and so overcomes locational disadvantage. a control variable social capital is implemented as a multi-item measure, with three selfreported items from the bhps, all on five-point likert scales, as follows. respondents rated the degree to which they: belong to their neighborhood; can access advice locally; and talk to neighbors. these items all correspond to well-established notions of social capital implemented in prior research (e.g., lochner et al. 1999 ). cronbach's alpha for these items is 0.74, suggesting good internal consistency. fourth, individual preferences may also influence choices. for example, if homeworking offers a safer environment, removing exposure to expensive business premise leases, more risk-averse people might become homeworkers. to measure risk tolerance, we used the following bhps question: "are you generally a person who is fully prepared to take risks or do you try to avoid taking risks?". respondents answered on a 10-point scale, ranging from 1 ("won't take risks") to 10 ("ready to take risks"). this serves as a direct, self-reported measure called risk tolerance. survey measures of risk tolerance are widely used by economists, and they appear to be reliable (dohmen et al. 2012) . fifth, freelancing arguably lends itself more readily to homeworking than other self-employed individuals, since freelancers often enjoy freedom about where they work. a dummy variable freelance is therefore included as a control. we also added five industry dummy variables that are salient for homeworkers. retail, construction, education, health and social work, recreational, cultural and sporting activities are coded as one if individual is working in respective industries, and zero otherwise. tables 8, 9, 10, 11, and 12 of the appendix outline the industry sectors that are included as dummy variables and the number of homeworkers in those industries. additionally, a dummy variable full-time venture is included which equals one if the self-employed is working fulltime for their business, and zero otherwise. we also created a dummy variable switch based on current and previous employment status, coded as one if selfemployed respondents had switched into their current business from paid employment, and zero otherwise. sixth, previous research (e.g., reuschke 2016) has identified housing characteristics as possible determinants of homeworking decisions. thus, we control for the number of rooms, since more rooms presumably makes it easier for the entrepreneur to set up a home office. we also use dummy variables to control for the type of dwelling, such as detached, semi-detached, terraced, and flat (i.e., apartment). it also seems plausible that homeowners face fewer restrictions than renters on configuring their dwellings for business use. hence, we added the dummy variable homeowner to the list as well. seventh, regional characteristics may also affect the homeworking decision. to start with, regions with high average house prices tend also to have higher business office rents (dobson and goddard 1992) and so are more likely to induce entrepreneurs to work from home if they can. in addition, higher regional average earnings tend to be concentrated in urban centers where there is a higher density of consumers (dumais et al. 2002) . the greater that demand, the more profitable it will be for entrepreneurs to locate their businesses nearby, to maximize their ability to capture the value associated with it. this may reduce homeworking, as may a non-urban location for the entrepreneur's main residence. to control for these possible factors, we obtained confidential local authority districts (lad) data from the bhps and matched it to the individual-level dataset. lads are a level of subnational division of the uk used for the purposes of the local government. there are 326 lads in england, 22 in wales, and 32 in scotland. lad-level average house price data from 2004 to 2008 were obtained from the uk house price index (uk hpi) dataset. the uk hpi uses house sales data from hm land registry, and registers of scotland. house sales data are compiled by the office for national statistics (ons). we used average house price data of each lad as of december of each calendar year and log-transformed the numbers to generate the control variable house price. average earnings for each lad were taken from ons, earnings and hours worked, place of residence by local authority: ashe table 8 . we used table 8 .7a (annual pay) of each year during 2004-2008. we had to map each ashe unit code to corresponding lad codes to transform the data to lad level. these data were used to compute a logtransformed local earnings variable. note that for all cases, house price and local earnings exhibit variation from year to year. additionally, we collected data on the local unemployment rate, unemployment rate, at the lad level from uk's office for national statistics (ons). finally, we also collected data on urban/rural classifications from the government of the uk (for england), scottish government (for scotland), and ons (for wales) to code a dummy variable urban, which equals one if the respondent lives in an urban and zero if they live in a rural area. details about these data sources can be found in appendix 2. table 1 provides some descriptive statistics about the characteristics of self-employed homeworkers ("h/w"), vis-a-vis non-h/w self-employed and employees. table 2 presents the pairwise correlation matrix. we start by comparing self-employed homeworkers with self-employed non-homeworkers in columns (1) and (2). some comparisons with employees in general (columns (4) and (5)) will also be made. self-employed homeworkers are substantially and significantly (p < 0.001 using a χ 2 test) less likely to be employers than other self-employed. this proffers some preliminary support to hypothesis 1. second, selfemployed homeworkers are also significantly less likely (p < 0.001 using a χ 2 test) than other self-employed to be in a business partnership, but are significantly more likely to be caregivers of disabled family members (p < 0.05 using a χ 2 test) and dependent child (p < 0.001 using a χ 2 test)-in accordance with hypotheses 2a and 3a. turning to the control variables, there is no significant difference between homeworkers and other selfemployed in terms of home ownership (p > 0.5). hence, homeworking is not clearly associated with home-owning status. the same is true of being a graduate. among the self-employed, women are disproportionately found in the homeworker category (p < 0.001), as would be expected if women entrepreneurs value flexibility more than men. this difference within the self-employed group also applies to work-limiting health conditions (p < 0.05). among the self-employed, homeworkers are significantly less likely (p < 0.001) to be in the retail or construction sectors, as expected. on the other hand, homeworkers are significantly more likely to be in the education (p < 0.001) and health and social work sectors (p < 0.05), compared with other selfemployed individuals. self-employed homeworkers are also older on average than other self-employed workers. this difference is significant across the four groups in table 1 according to anova tests [f(1, 4694) = 102.7, p < 0.001]. table 1 also suggests that self-employed homeworkers possess the most social capital. this difference is statistically significant across all four groups [f(3, 28,537) = 27.97, p < 0.001] as well as across the two self-employed groups [f(1,3180) = 43.1, p < 0.001]. self-employed homeworkers are no more or less likely to be freelancers (p > 0.05), but they are less likely to live in urban areas than other self-employed workers (p < 0.001 using a χ 2 test). self-employed homeworkers are also less likely to be operating full-time (p < 0.001) but are more likely to be living in detached houses (p < 0.001) with more rooms [f(1, 4222) = 52.0, p < 0.001] than other selfemployed workers. finally, table 1 also indicates that self-employed homeworkers differ in several important respects from employee homeworkers. employee homeworkers are significantly more likely than their self-employed counterparts to be female and caregivers, and to be graduates; they are also younger. overall, these findings validate the choice to study self-employed homeworkers separately from employee homeworkers. we test our hypotheses using a random effects probit model. a random effects model was preferred to a fixed effects model because it can estimate the effects of timeinvariant variables. moreover, a fixed effects model would only identify switchers into and out of homeworking, which drops too many observations and besides is not the sample of interest in this study. it is possible that the variable employer is endogenous. to explore this possibility, we used two different approaches. first, we estimated a three-stage-least-squares (3sls) linear probability model, using type 1 (risk tolerance for employer equation) and type 2 instruments (caregiving for homeworking equation) for these two equations. these estimates (details available on request) revealed that homeworking is an insignificant predictor of being an employer. we also estimated a seemingly unrelated (sur) bivariate probit model with two endogenous variables: homeworking and employer. a sur bivariate probit model allows the error terms of two equations to be correlated. if the equations are not independent of each other, they must be estimated as a system. however, for this model, the wald test of independent errors cannot be rejected, again suggesting an absence of endogeneity between the homeworking and employer equations (details also available on request). based on these results, we proceeded to estimate homeworking in a single equation specification. finally, to explore the possibility that homeworking is merely a transitional work arrangement that precedes larger-scale entrepreneurship, we also compute transition matrices and estimate probit models predicting transitions into homeworking and non-homeworking. we first present the results from estimating the random effects probit model using the total sample, before presenting the results separately for males and females, consistent with our conceptual analysis. we then go on to explore whether homeworking is a transitory state for businesses. model (1) of table 3 displays the estimation results for the total sample, while models (2) and (3) do so for the male and female subsamples respectively. we see that the propensity of entrepreneurs to choose homeworking and hire employees is negatively related for the total sample (p < 0.001), the male subsample (p < 0.001), and female subsample (p < 0.05). thus, hypothesis 1 is supported. also, business partnerships are negatively related to homeworking for the total sample (p < 0.01) and the male subsample (p < 0.001), supporting hypothesis 2a. this relationship is weaker for females, consistent with hypothesis 2b. hypothesis 3a predicted that caregiving responsibilities are positively related to the propensity of entrepreneurs to choose homeworking. also, hypothesis 3b predicted that caregiving responsibilities will make self-employed women more likely to choose homeworking than self-employed men. both hypotheses 3a and 3b are supported when caregiving responsibilities entail having a dependent child in the household: the effect is statistically significant for females (p < 0.05) but not males. in contrast, having caregiving responsibilities for disabled persons is not significantly related to the homeworking decision of self-employed individuals. it is possible that self-employment provides enough flexibili ty t o discharge caregiving turning to the control variables, we find positive associations between homeworking and each of age, social capital, and working in the education sector for the total sample and the male subsample. the number of rooms in one's house is also positively related to the homeworking decision, especially for women. strikingly, though, few other relationships approach conventional levels of statistical significance-including having a work-limiting health condition. on this last point, it is again possible that self-employment provides sufficient flexibility to accommodate this without needing homeworking. all of the results so far relate to influences on homeworking, as discussed in the "factors influencing homeworking" section. we turn next to the primary research question, which is whether homeworking is a transitory state for fledgling businesses. as noted in the "is homeworking a transitional state?" section, if that is the case, one might expect numerous hybrid entrepreneurs to transition into homeworking from year to year. to check whether this notion gains empirical support, table 4 presents the year-to-year transition matrix for hybrid and non-hybrid entrepreneurs, calculated by pooling every wave of the sample. the table shows that, among non-hybrid entrepreneurs, there are relatively high annual transition rates (11-17%) between homeworking and non-homeworking. in contrast, virtually no hybrid entrepreneurs make transitions into homeworking-or even out of hybrid status. hence, homeworking does not seem to be a risk-minimization strategy for hybrid entrepreneurs, casting doubt on the notion that homeworking is an entry point for entrants using this strategy. as a side note, the low rate of transitions out of hybrid entrepreneurship and into fulltime entrepreneurship (1.8%) is striking, and contrast continuing with the question of whether homeworking is a transitory haven for fledgling businesses, we next tested hypotheses 4a and 4b. to that end, we estimated a probit model with two dependent variables-(1) nonhomeworking self-employed who are employing others, and (2) non-homeworking self-employed with business partners. in accordance with the phrasing of hypotheses 4a and 4b, last year's homeworking status was included as the main independent variable. table 5 presents the results. we start with model (4), which reveals that the previous year's homeworking status is positively related to the homeworking status in the current year (p < 0.001). thus, self-employed homeworkers are significantly more likely to remain in this state than to transition to non-homeworking status. strikingly, model (5) indicates that the previous year's homeworking status without employing others is negatively related to current non-homeworking status while employing others (p < 0.001). hence, we reject hypothesis 4a, and infer that homeworking is not merely a temporary repository of businesses that subsequently hire employees and transition to non-home-based locations. along similar lines, model (6) indicates that the previous year's homeworking status without business partners is negatively related to current nonhomeworking status with business partners (p < 0.001). this leads us to reject hypothesis 4b. overall, these results indicate that homeworking is more than a transitional phase for fledgling businesses. this section closes with several robustness checks. first, we tested a probit model using stabilized weights to account for possible selection bias associated with the self-employed differing from other workers based on a set of observables. to this end, we calculated inverse probability of treatment weights (iptw) to control for selection on observables (azoulay et al. 2009; fewell et al. 2004 ). we defined self-employed individuals as the treated group and employed individuals as the control group and computed stabilized weights for the members of both groups. finally, we re-ran the pooled probit regression model using stabilized weights. we repeated this procedure for total sample, male subsample, and female subsample. table 6 displays the estimates of the pooled probit model using stabilized weights. model (7) presents findings for the total sample, while models (8) and (9) present the findings for the male and female subsamples, respectively. hypothesis 1, which predicted a negative relationship between being an employer and homeworking, continues to receive support-for all three samples (p < 0.001). likewise, hypothesis 2a, which predicted a negative relationship between business partnerships and homeworking, continues to receive support for male subsample (p < 0.05)-as does the weaker relationship for females (hypothesis 2b). however, we discern no significant relationship between caregiving responsibilities of disabled family member and dependent child and propensity to choose homeworking, for all three samples. therefore, hypotheses 3a and 3b are not supported in our robustness checks. also, once we control for sample selection, being a homeowner is negatively related to homeworking overall and for the female self-employed subsample. perhaps female homeowners are wealthier than female non-homeowners and wealthier females can afford office rent for their own business, which is related to their decision to eschew homeworking. for the female subsample, the number of rooms in house is positively related to homeworking, which seems intuitive. second, we tested whether interaction variables of different items related to caregiving responsibilities are related to the homeworking decision of entrepreneurs. in additional (unreported) tests, we found that the interaction of providing caregiving to a disabled person and providing caregiving to a dependent child was not a significant predictor of self-employed homeworking. also, the interaction of providing caregiving to a disabled person and providing caregiving to a dependent child as a single parent was not significantly related to self-employed homeworking, either. nor was the interaction of providing caregiving with single parenthood. third, the number of hours worked in a business may affect the propensity to choose homeworking. we did not include this variable in the full model earlier because of the possibility it might be endogenous. yet adding this variable to the model yielded an insignificant coefficient (details available on request). fourth, we tested whether age has different functional forms such as quadratic or discontinuities around 65. however, we did not find significant effects from including higher-order terms or age discontinuity dummies (results also available on request). we therefore conclude that our results appear to be fairly robust to different model specifications. this article has highlighted an important but hitherto largely overlooked aspect of entrepreneurship, namely the to fill this gap, we proposed some novel hypotheses about the determinants of entrepreneurial homeworking and tested them using a large sample of panel data. the most notable finding is that homeworking does not seem to serve as a transitional state for fledgling new businesses before they scale and professionalize and transition to non-homeworking firms. if it did, one might expect to observe numerous "hybrid" entrepreneurs, who work primarily in paid employment practicing selfemployment as a second job, transitioning into full-time non-homeworking self-employment. we would also expect to observe entrepreneurs who take on employees and business partners to transition away from homeworking and into non-home-based businesses. in fact, the evidence failed to support any of these predictions. one is therefore led to conclude that homeworking is an integral and stable manifestation of entrepreneurship. that being the case, we went on to explore what factors influence individuals' decisions to choose homeworking. we found that self-employed homeworkers are significantly less likely to be employers or to have business partners, with stronger relationships between these variables observed for male than female entrepreneurs. we found a significant relationship between providing caregiving to a dependent child and homeworking among the self-employed, for women specifically. however, to our surprise, we detected no significant relationship between providing caregiving to disabled family members and self-employed homeworking among our respondents, including for the female sample. the lack of a significant association between caregiving of disabled family members and self-employed homeworking seems to fly in the face of prior theorizing and previous empirical findings. one possibility is that self-employment provides enough flexibility in the british context to enable entrepreneurs to discharge their caregiving obligations to disabled family members, such that homeworking confers no additional advantages in this regard. the precise nature of the ventures that the self-employed operate may be relevant in this regard: exploring this possibility further and in greater detail provides an opportunity for future research. our findings may carry implications for entrepreneurship scholars wrestling with two puzzles. one puzzle is the limited number of entrepreneurs who create jobs for others-an important issue given strong policy interest in, and encouragement, of job creation (caliendo and kritikos 2010; henley 2005; mathur 2010; michaelides and benus 2012) . the present article has identified homeworking as a hitherto overlooked explanation for limited job creation. homeworking can help explain the limited scale of most entrepreneurial ventures (davidsson et al. 2009; hurst and pugsley 2011) and their surprisingly limited growth ambitions (delmar and wiklund 2008; wiklund and shepherd 2003) . the logistical difficulties of operating a multiperson venture from a domestic property, together with the agency costs entailed by spatially separating employees from the entrepreneur owner-manager, could account for incompatibility between entrepreneurial homeworking and job creation. combined with the prevalence and persistence of homeworking, the weak job creation performance of the self-employed may become more understandable. a second puzzle in the entrepreneurship literature is the apparent earnings penalty entailed by selfemployment; contrary to the earnings premium, one might expect the self-employed to receive in return for bearing greater risk (hall and woodward 2010; manso 2016) . if self-employed homeworkers earn less on average than their non-homeworker counterparts, e.g., because of a positive "compensating differential" derived from working at home, then this might explain part of the puzzle. the idea behind the compensating differential is that a pleasant non-financial feature of a working arrangement (e.g., being based at home) can compensate for lower financial remuneration, thereby inducing some entrepreneurs to take low-income business opportunities which they might otherwise forgo. consistent with this logic, some income calculations by the authors using the bhps revealed a much greater pre-tax earnings penalty for homeworker self-employed than for non-homeworker self-employed. these calculations used data on pre-tax earnings, and computed averages for paid employees, homeworker selfemployed, and non-homeworker self-employed. they revealed that the average pre-tax earnings penalty of all self-employed relative to employees was £240 per month, whereas self-employed homeworkers earned on average £738 per month less than the nonhomeworker self-employed (all amounts in 2008 prices). in fact, were one to remove homeworkers from the self-employed sample, the £240 per month selfemployment penalty relative to employees would be turned into a £58 per month premium. hence, homeworking may partly explain lower average overall self-employment incomes compared with employees. homeworking is not only widespread but also carries implications for policymakers wanting to promote entrepreneurship. to start with, growing evidence suggests that locally based entrepreneurship contributes significantly to the development of peripheral regions (baumgartner et al. 2013; stephens and partridge 2011) . in the usa, for example, home-based ventures make an especially important economic contribution in places that struggle to attract large retailers or manufacturing plants (rowe et al. 1999 ). entrepreneurial homeworking might therefore be crucial for revitalizing local communities facing geographic and economic barriers. we generated some tentative evidence (table 6 , column (7)) that high-tech workers are more likely to become self-employed homeworkers. to the extent that high-tech workers need access to high-quality digital infrastructure, our research might also carry implications for technology policy. for example, malecki (2003) has highlighted shortcomings in the us digital infrastructure which may be holding peripherally located businesses back. in the uk, in march 2020, chancellor of the exchequer rishi sunak promised more than £5bn of investment into britain's digital infrastructure, to be used to spread gigabit broadband to remote corners of the uk, benefitting more than five million homes and businesses. this budget announcement followed a pledge by prime minister johnson that every home would have access to the next generation of internet technology by 2025. this type of infrastructure investment, which is rolling out in many other countries as well, is likely to increase the ease with which techbased businesses can be operated at home, especially given continued growth in the number of internet-based ventures (and possibly also in response to the covid-19 pandemic). given ongoing discussions about "the future of work" which may involve greater use of homeworking and self-employment, this initiative and others like it could fuel growth in the number of entrepreneurial homeworkers in the years ahead. further research is needed to quantify the social welfare implications of entrepreneurial homeworking relative to alternative work arrangements. that could shed light on the impact of other policy instruments such as zoning laws and rent subsidies, which might also affect the entrepreneurial choices explored in this article. mason et al. (2011) noted that planning laws, regulations, and tax rules were formulated decades or even centuries before the digital knowledge-based economy was envisaged. policy changes may be needed to support home-based entrepreneurship in this new context, for example by allowing social housing residents to start home-based businesses to escape poverty and worklessness. the task of formulating detailed policies in this regard is likely to be complex and multi-faceted: we leave it to future work. future research may also seek to address several limitations of the present article. first, the present paper abstracted from several important considerations, including endogenous worker mobility, entrepreneur mobility, and the determination of business office rents. some prior research (e.g., rosenthal and strange 2012) has explored some of these issues, though not in the context of homeworking decisions. a fuller treatment of these issues would seem worthwhile. second, among the empirical limitations of this article one may question the use of self-employment as a measure of entrepreneurship. it would be interesting to know whether the results obtained here continue to hold for alternative definitions of entrepreneurship; and to quantify the amount, type, and determinants of homeworking using alternative definitions. third, it would be valuable to utilize data from other countries and investigate temporal variations and trends in the phenomenon of selfemployed homeworking. these tasks are all left for future research. fourth, industry controls and possibly several other variables, such as work hours and earnings, may be jointly determined with homeworking. thus, the paper should be regarded as exploratory and correlational in nature: it does not make strong claims about uncovering causal relationships. fifth, our investigation did not exhaust all forms of risk-minimization strategies associated with homeworking. for instance, it is possible that some self-employed homeworkers organize as sole proprietors, and switch to incorporated status and nonhomeworking. we lack the data to explore this possibility in our study, though we note that prior research suggests that this kind of transition is infrequent (åstebro and tåg 2017) . to conclude, entrepreneurial homeworking is simultaneously a widespread and a sorely understudied phenomenon. more research is needed on this topic, in part to inform entrepreneurs and policymakers, and in part to build out scholarly understanding of entrepreneurship. its prevalence alone makes it deserve of further attention; but one can also imagine a whole set of questions which researchers can explore anew by distinguishing between homeworker and non-homeworker entrepreneurs. for example, are borrowing constraints different for the two groups of entrepreneurs, and are the growth and survival prospects of their ventures different too? how does the growing trend of flexible "gig economy" working and multiple job holding (adams et al. 2018) intersect with homeworking among the self-employed, and what are the likely directions this may take in the future? what are the regional impacts of homeworking in terms of economic development and living standards? these are all interesting questions which the homeworker distinction open up for fresh investigation, and which promise to generate further unexpected and fruitful insights. office for national statistics (ons), earnings and hours worked, place of residence by local authority: ashe table 8 open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, 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growth: the moderating role of resources and opportunities key: cord-329291-wx1g8i3o authors: amster, roi; reychav, iris; mchaney, roger; zhu, lin; azuri, joseph title: credibility of self-reported health parameters in elderly population date: 2020-06-10 journal: prim health care res dev doi: 10.1017/s1463423620000201 sha: doc_id: 329291 cord_uid: wx1g8i3o aim: examining the credibility of self-reported height, weight, and blood pressure by the elderly population using a tablet in a retirement residence, and examining the influence of health beliefs on the self-reporting credibility. background: obesity is a major problem with rising prevalence in the western world. hypertension is also a significant risk factor for cardiovascular diseases. self-report, remotely from the clinic, becomes even more essential when patients are encouraged to avoid visiting the clinic as during the covid-19 pandemic. self-reporting of height and weight is suspected of leading to underestimation of obesity prevalence in the population; however, it has not been well studied in the elderly population. the health belief model tries to predict and explain decision making of patients based on the patient’s health beliefs. methods: residents of a retirement home network filled a questionnaire about their health beliefs regarding hypertension and obesity and self-reported their height, weight, and blood pressure. blood pressure, height, and weight were then measured and compared to the patients’ self-reporting. findings: ninety residents, aged 84.90 ± 5.88, filled the questionnaire. from a clinical perspective, the overall gap between the measured and the self-reported bmi (m = 1.43, sd = 2.72), which represents an absolute gap of 0.74 kilograms and 2.95 centimeters, is expected to have only a mild influence on the physician’s clinical evaluation of the patient’s medical condition. this can allow the physician to estimate their patient’s bmi status before the medical consultation and physical examination upon the patient’s self-reporting. patients’ dichotomous (normal/abnormal) self-report of their blood pressure condition was relatively credible: positive predictive value (ppv) of 77.78% for normal blood pressure (bp) and 78.57% for abnormal bp. the relatively high ppv of bp self-reporting demonstrates an option for the physician to recognize patients at risk. regression analysis found no correlation between the anthropometric parameters and the health belief model. obesity is widespread in the western-world population and causes major medical concerns due to its direct link to increased risk of mortality (flegal et al., 2005) . in addition to mortality, obesity has been demonstrated to correlate with many medical conditions such as diabetes (mushcab et al., 2017) , hypertension, and cardiovascular disease (flegal et al., 2002) . body mass index (bmi) is a common and effective method to estimate obesity since its components (height and weight) are readily available and easy to measure. the widespread use of bmi enables researchers to compare results in different studies (flegal et al., 2013) . particularly among older population members, very high or very low bmi correlates with higher mortality (miller and wolfe, 2008) and therefore becomes an indicator that an individual needs to be under close medical observation. hypertension is the third most influential mortality factor (ezzati et al., 2002) and is responsible for at least 45% of deaths due to heart disease and more than 50% of deaths due to stroke (who, 2013) . hypertension prevalence rises in the older population, resulting in higher levels of treatment within this group (ong et al., 2007) . blood pressure measurement is the primary tool for diagnosis, management, treatment, and research of hypertension (o'brien et al., 2005) . self-reported data for height and weight is commonly used, but can lead to underestimating obesity since people tend to report greater heights, and lower weights than actual measurements indicate (ahima and lazar, 2013; hattori and sturm, 2013) . the credibility of self-reported height and weight can be estimated by the gap between self-reported data and measured data. self-reporting of blood pressure has also been researched, but the evidence is inconsistent concerning its overall credibility (goldman et al., 2003; chun et al., 2016) . the credibility of self-reported bp can be estimated by the gap between self-reported data and measured data or by comparing patients' dichotomous (normal�bnormal) selfreport of their blood pressure to their actual bp measurement. as life expectancy keeps rising, and the percentage of elderly, aged 65 and older (brody et al., 1987; kaye et al., 2010) , is expected to increase, medical systems will need to treat more and more older patients who require close monitoring and engage in selfmanagement practices (morgan et al., 2017) . past studies have shown that the lack of time takes a toll on the ability of physicians to treat their patients (yarnall et al., 2003) . self-reporting using digital aids can be another tool in the physician's arsenal that could help monitor patients (linderholm et al., 2019; pereira et al., 2019) . self-reporting, while practicing telemedicine, becomes even more essential when patients are encouraged to avoid visiting the clinic as during the covid-19 pandemic (hollander and carr, 2020) . however, this is only useful if self-report credibility can be improved. the health belief model (hbm) predicts and explains patient decision making related to medical issues (jones et al., 2015) , for instance, in the context of diabetes (gillibrand and stevenson, 2006) or breast cancer (norman and brain, 2005) . the model suggests patients' decisions correspond to her or his evaluation of the four following factors: perceived benefits, perceived barriers, perceived severity, and perceived susceptibility (rosenstock, 1966 (rosenstock, , 1974 . in general, the model's ability to predict and explain patterns of behavior has been proven many times (janz and becker, 1984) . in particular, the hbm model succeeded in predicting medical decision approaches among older population members (rundall and wheeler, 1979; esmaelzadeh et al., 2018) and others (shafer et al., 2018) . however, this model was not used to investigate its effectiveness in predicting self-reported health parameters' credibility. our goal in this study is to examine the credibility of self-reported height, weight, and blood pressure by the elderly population living in a retirement residence to a tablet and explore the influence of health beliefs on the self-reporting credibility. the study was conducted in a network of three retirement residences. all residents are at least 65 years old. all subjects who volunteered for the study were 70-97 years old, ambulatory, and without any significant cognitive impairment. the residents were invited to participate in the study through advertising inside the retirement residences. the sample size was estimated to be at least 85 participants using winpepi software (abramson, 2004 ), based on 5% significance level and 80% power level and a t-test for correlation between the anthropometric variables and hbm score with a clinical significance of r = 0.30. the questionnaire (appendix 1) was based on questions derived from prior studies that dealt with the relation between hbm and obesity or hypertension (weissfeld et al., 1990; desmond et al., 1992; park, 2011; scotland, 2012) . the questions were scored on a 1-5 scale (strongly agree-strongly disagree). the questions were translated and proofread after adaptation to the study population. the study's demographic questions included age, gender, education, religious status, hospitalization, and frequency of visiting doctors and nurses in the past year. at the end of the questionnaire, the participants were asked to self-report height, weight, and blood pressure to the best of their knowledge, and to grade their blood pressure as low, normal, or high. the questionnaire was first executed as a pilot to five participants over the age of 65 years that visited a primary medical clinic. minor changes to wording resulted. each study day, residents living in "bait balev" retirement residences network were invited to participate in the study. the residents were asked to fill in a digital version of the questionnaire on a tablet. finally, a team member measured and recorded the participant's actual parameters. all data were kept anonymous. blood pressure measurements were completed according to the joint national committee (jnc) recommendations (chobanian et al., 2003) . each participant was measured three times, and the average of the second and third times was recorded. two of the 90 participants refused to complete the third measurement, and their second measurement was recorded. systolic blood pressure (sbp) higher than 160 or diastolic blood pressure (dbp) higher than 100 was immediately reported to the medical staff in the retirement residence for further consideration of medical actions. in the current study, we used three standard adult-elderly population thresholds for systolic blood pressure hypertension (mancia et al., 2009) : sbp < 140valid for all adult population; sbp > 160begin treatment in elderly (>80 yrs); sbp = 140-150 target pressure for elderly (>80 yrs). measured and reported bmi were calculated by weight (in kilograms)/height (in meters) 2 that were measured or reported, respectively. bmi data were analyzed and broken into categories described as underweight (bmi below 18.5), normal (bmi 18.5-24.9), overweight (bmi 25.0-29.9), and obese (bmi above 30.0). bmi and sbp gaps were defined as the difference between the reported to the measured bmi and sbp, respectively. data were presented using descriptive statistics and analyzed by student t-test and regression model. all data analyses were completed using spss software. the study was approved by the bait balev local ethics committee (irb) before commencing the trial (bbl-0063-18). a waiver was given for written informed consent from patients as all the questionnaires were fully anonymized. between may and august 2018, 90 residents participated in the study. only two residents that we approached refused to participate. table 1 shows the demographic and general characteristics of the participants, and table 2 summarizes the measured and self-reported bmi and bp. the categorized calculated self-reported bmi (underweight 1.14%, normal 34.09%, overweight 44.32%, and obese 20.45%) vs. the measured bmi (1.14%, 28.41%, 31.82%, and 38.63%, respectively) were lower for the obese group and higher for the normal and overweight groups. overall, 45.55% of the study participants self-reported their blood pressure while 54.45% did not know their actual blood pressure levels and therefore did not report it. of those responding, 80.00% of the participants self-reported that their blood pressure was normal, 15.56% self-reported that it was high, none reported low, and 4.44% self-reported they did not know. (table 3) . for participants who reported normal bp (n = 72), a measured sbp of <160 was observed in 56 participants (average bp 137.02/77.46), while 16 participants of this group had an actual high pressure (average bp 181.62/90.31). for participants who reported high pressure (n = 14), a measured sbp of >140 was observed in 11 participants (average bp 178.63/88.64), while only 3 participants of this group had an actual normal bp (average bp 131.13/77.66). significant gap comparisons in bmi and sbp were found, and the analysis by different bmi categories is shown in table 4 . data from the questionnaires were used to calculate hbm scores. eight of the ten different questionnaire categories had a cronbach's alpha higher than 0.60 (table 5) . we used a regression analysis to test the correlation between height, weight, and bmi gap and the relationship of these items to gender-adjusted hbm scores. the following results were found: bmi gap -the results of the regression indicated that the seven variables explained 17.50% of the variance of bmi gap (r 2 = 0.17, f (7,81) = 2.19, p < .05). perceived severity significantly predicted bmi gap β = −1.32, t(81) = 0.43, p < .001, which indicated when perceived severity increased, the height gap decreased. gender was also a significant factor affecting the bmi gap, β = 1.67, t(81) = 0.74, p < .05, which indicated that female self-reports had a higher bmi gap than male's self-reports by 1.67. height gapthe results of the regression indicated that the seven variables explained 16.50% of the variance (r 2 = 0.16, f(7,80)= 2.25, p < .05). perceived severity significantly predicted the height gap, β = 2.71, t(80) = 0.89, p < .01. it indicated when perceived severity increased, the height gap increases. weight gap -perceived barriers 2 significantly predicted the weight gap, β = −1.53, t(81) = 0.63, p < .05, which indicates when the perceived barriers increases, the weight gap decreased. but the f-statistic was insignificant, which suggests the value of the model is very limited on the weight gap. in a regression that tested the correlation between bp gap and gender-adjusted hbm score, we determined that perceived susceptibility significantly predicted dbp, β = −6.67, t(34) = 2.95, p < .05, which indicated when the participant perceived susceptibility increased, the dbp gap decreased. furthermore, we ran a logistic regression and analyzed the self-reported bp status and measured bp status. the results were not significant. the chi-square test may have indicated the self-reported data did not have enough power to infer the measured bp. since r 2 was relatively low in both cases, even though there were some significant findings, we believe that the hbm score does not explain either the bmi gap or the bp gap. therefore, generally, we would say that the hbm score was not a good predictor for self-reported data credibility. regression analysis was used to test the correlation between height, weight, blood pressure, and bmi gap. the relationships of these items to gender-adjusted hbm score and demographic parameters were not significant. the elderly population is a unique population that requires closer than average monitoring due to their higher incidence of morbidity and mortality (kennedy et al., 2014) , and bp and bmi measurements can alter the medical approach to this population. bmi -body mass index. self-reported bmi refers to the calculation of the self-reported measurements. we excluded one self-reported height of a 162 cm woman who said she doesn't know her height, but because it was mandatory to self-report she wrote she is 115 cm. roi amster et al. self-reporting of blood pressure and anthropometric parameters can assist triage and simplify a remote approach to the patient. as there is still a lack of data in the literature regarding the elderly population, the current study examined the credibility of selfreporting by the elderly population living in a retirement residence. in the older population, in particular, very high or very low bmi correlates with higher mortality (miller and wolfe, 2008) and therefore suggests closer monitoring for the patient. from a clinical perspective, the overall bmi gap in the current study (m = 1.43, sd = 2.72), which represents an absolute gap of 0.74 kilograms and 2.95 centimeters, is expected to have only a mild clinical influence, if any, on the physician's evaluation of the patient's medical condition. this can allow the physician to estimate their patient's bmi status before the medical consultation and examination upon the patient self-reporting. previous studies showed self-reported heights to be higher and weights to be lower than the actual measurements (ahima and lazar, 2013; hattori and sturm, 2013) . however, this study shows the anthropometric indices' credibility to be highest in the normalweight group (bmi gap: m = −0.02, sd = 2.01), deteriorate through overweight's (m = 1.52, sd = 1.83) and to be worst in the obese group (m = 2.24, sd = 3.34). taking into account the actual bmi group levels, these bmi gaps should not make a significant change in the clinical approach to the patient, which makes the height-weight-bmi self-reporting even more credible in the clinical perspective. similar to the lower credibility in the bmi self-report, the obese patients were also less credible in bp self-reporting in comparison with the normal-weight group. this could be due to several reasons such as that the individual is not willing to accept their current health risk, society's general view of obesity, and the pressure that puts on an individual to conform to an`acceptable' archetype or the individual's body image as healthy or not. further studies are needed to address these questions. in this study, there was a high yield between the participants' definition of normal vs. high blood pressure and their self-report of blood pressure values (133.38/72.13 vs. 146.00/81.60, respectively). target blood pressure for the oldest-old people, aged 85 and older (rosenwaike, 1985; rogers, 1999) , has long been debated, and inconsistencies regarding the optimal bp for this population exist in different guidelines since there is a lack of clear evidence regarding this issue (garrison et al., 2017; anker et al., 2018) . patients' dichotomous (normal�bnormal) self-report of their blood pressure condition was relatively credible: positive predictive value of 77.78% for normal bp (sbp < 160) and 78.57% for abnormal bp (sbp > 140). these relatively high ppvs could help physicians identify patients at risk through self-report outside of the medical encounter, e.g., if a patient claims a normal bp, it would be reasonable to assume there is no need for a change in hypertension treatment; while for those who claim a high bp, it warrants a close follow up and bp measurements. nevertheless, as the ppv is not as accurate as a real measurement, we find this method relevant for monitoring patients from afar, but not as a replacement for actual measurement during the medical encounter. the hbm was not used previously to investigate its effectiveness in predicting self-reported health parameters' credibility. in the current study, we also concluded hbm score was not a sufficient predictor for self-report credibility. more research remains to determine if there is better predictability of self-report in other hbm subtypes. the gap between measured and self-reported bmi has only a mild influence regarding the evaluation of a patient's metabolic status. therefore, we recommend considering the use of self-reporting weight and height using a tablet among the elderly population when direct measurements cannot be taken. covid-19 pandemic emphasizes the need for the physician to monitor his patients from afar due to the current need to minimize physical encounters. self-reporting has the potential to be an essential tool in the physician's toolbox while practicing telemedicine. the relatively high ppv of bp self-reporting demonstrates an option for the physician to recognize patients at risk. further studies could identify the most credible subjects in this area. membership bias could be present because the population who lives in the retirement residence were generally of higher socioeconomic levels than the general population. another potential bias is volunteering bias because participation was not mandatory; hence participants might be more aware of their medical condition and might possess better than average medical knowledge. however, in the current study, refusal to participate was negligible. finally, the use of self-reporting to a tablet was also a potential limitation, especially in the elderly population. however, this issue was shown not to be a significant limitation, as the questionnaire was very intuitive and user friendly. help was given to few participants who required specific instructions on how to use the tablet. winpepi (pepi-for-windows): computer 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services historical origins of the health belief model a demographic portrait of the oldest old factors associated with utilization of the swine flu vaccination program among senior citizens in tompkins county health beliefs and knowledge related to management of hypertension among adult dominicans applying the health belief model and an integrated behavioral model to promote breast tissue donation among asian americans health beliefs in a population: the michigan blood pressure survey a global brief on hypertension: silent killer, global public health crisis: world health day primary care: is there enough time for prevention? acknowledgments. this work was performed in partial fulfillment of the md thesis requirements of the sackler faculty of medicine, tel aviv university.authors' contribution. all authors have made a substantial, direct, intellectual contribution to this study. key: cord-017479-s4e47bwx authors: pulcini, elena title: spectators and victims: between denial and projection date: 2012-03-16 journal: care of the world doi: 10.1007/978-94-007-4482-0_6 sha: doc_id: 17479 cord_uid: s4e47bwx this chapter goes into the unproductive metamorphosis of fear, and analyses the defence mechanisms that it generates: namely denial and projection. in the case of global risks, fear provokes self-defensive strategies based on denial (in the face of the nuclear challenge) and self-deception (in the face of global warming); and, in the case of the threat of the other, projective and persecutory strategies based on reactivating the dynamic of the ‘scapegoat’. they are two contrasting but specular responses which, at the emotional level, reflect the divarication between (unlimited) individualism and (endogamous) communitarianism. the first, implosive response converts into an absence of fear, attested to above all by the figure of the global spectator, while the second, explosive response converts into an excess of fear (fear of the other, fear of contamination), fuelled by forms of reinventing community. these responses are defined as irrational since in the first case they inhibit the spectator’s capacity to recognize himself as also a potential victim of the threats, thus preventing his mobilization, and in the second case they give rise to dynamics of demonization-dehumanization of the other, which result in a spiral of violence and impede forms of solidarity. this case a subjective factor comes into play, linked to the capacity and manner of perceiving the threats. it is telling that sociology and psychology converge on the importance of this aspect, underlining the fact that the very characteristics of the risk have a de fi nite in fl uence on the way in which it is perceived. 4 ulrich beck had already stressed the fact that the often invisible nature of the global risks, the unforeseeability of their effects and the only potential character of the damage which they provoke mean that they are removed from our perception and require the intervention of a re fl exive attitude interpreting the new scenarios through a knowledge that is equal to the new challenges. but in reality the problem is more complex still, since rather than an absence, we are faced with processes that distort the perception and assessment of the risk, which affect both the emotional and the cognitive spheres, and above all how they interact together. among the approaches sensitive to this problem, the one which seems to dwell on it most is cognitive psychology. starting from the classic studies by chauncey starr and then fischoff and slovic, 5 and on the basis of the so-called psychometric paradigm, cognitive psychology has built complex cognitive maps aimed at providing as exhaustive a list as possible of the variables that in fl uence the subjective perception of risk. the conclusions that have emerged from this interpretative approach show, for example, that concern in the face of threats (whether they derive from particular activities, substances or technologies) grows in correspondence to certain characteristics, amongst which the involuntary nature of the risks, the impossibility of controlling them, their capacity to cause irreversible damage and their originating from an unknown source. but above all, the results stress the fact that individuals are subject to distorted assessments and judgements in relation to the risks they are exposed to. for example, they tend to overestimate threats publicized by the media even if they are infrequent; to consider dangers dealt with voluntarily as more acceptable compared to those to which we are subjected or which are completely unprecedented or not very familiar; to feel fear in the face of very vivid events (11 september 2001), at the same time being quite incapable of a historical memory that links these same events together. while the merit of this approach is that it accepts and recognizes the presence of the subjective aspect and the uncertainty factor in de fi ning the concept of risk, pointing out the presence of non-rational responses, its limits lie, however, in its still strongly assuming the notion of probability. 7 namely, it ignores what is instead underlined by mary douglas, that is, the social and institutional context and the symbolic-cultural factors that in fl uence the perception of the threats, 8 and reproposes the idea of an essentially individualistic and de-contextualized social actor based on an abstract idea of rationality. finally, what we are most interested in here, in part deriving from the latter aspect, the limit of this approach lies in its failure to account for the why , the deep reasons that pollute a correct perception and assessment of the risks. in this connection, based on the reassessment of the role of emotions that has greatly questioned the hegemonic paradigm of rationality 9 over the last few decades, some authors have underlined that cognitive and emotional factors have to go together in order to recognize the existence of a risk and to weigh up its possible consequences. 10 they have put forward the idea that the information that enters our cognitive system can only have an effective impact on our action if it succeeds in creating images laden with emotion in our psyche. in other words, this means that we can be perfectly aware of particular threats without this involving us emotionally. put differently, only if this converts into the capacity to 'feel', to react emotionally and imagine its possible effects can our knowledge of the risk be effectively said to be knowledge, and therefore produce apt mobilization. now, the problem with regard to global risks seems to be prompted, as günther anders had already perfectly grasped in his diagnosis of fear in the age of technology, by the very imbalance between knowing and feeling. this imbalance is none other than one of the many variants of the psychic split that characterizes the contemporary subject and that anders, as has already been hinted, calls the 'promethean gap'. with this expression, he alludes in general to the detachment between the faculties, fi rst of all between the power to do and the capacity to foresee, which characterizes contemporary homo faber , or rather homo faber who has become homo creator . paradoxically what corresponds to the immense human power to 115 6.1 global risks and absence of fear produce and create permitted by developments in technology is man's inability to imagine its consequences: the faculties have got further and further away from each other so now they can no longer see each other; as they cannot see each other, they no longer come into contact, they no longer do each other harm. in short: man as such no longer exists, there only exists he who acts or produces on one hand, and he who feels on the other; man as producer and man as feeling, and only these specialized fragments of men have a reality. 11 no more are our imagination and our emotions equal to our unlimited power; at this point man's soul is irreparably 'outdated' with respect to what he produces and his colossal performances. in short, no more can we keep up-to-date with our promethean productivity and with the world that we ourselves have built: we are about to build a world that we cannot keep up with, and, in order to "catch" it, demands are made that go way beyond our imagination, our emotions and our responsibility. 12 this 'schizophrenia', 13 which is where the fundamental pathology of our time resides, prompts the paradoxical and ambivalent combination of power and impotence, activity and passivity, knowledge and unawareness that exposes the contemporary prometheus not only to previously inconceivable risks, but, also and above all, to the impossibility to recognize their destructive potential. this pathological drift appears particularly evident in the risk par excellence of the age of technology, which undermines not only the quality of individuals' lives (like in the case of the possible effects of the biotechnologies), but humankind's very survival on the planet: namely, the risk produced by the creation of the nuclear bomb, which we can recognize as the fi rst effectively global challenge. 14 before the horror of hiroshima and the spectre of humankind's self-destruction anders says: we really have gained the omnipotence that we had been yearning for so long, with promethean spirit, albeit in a different form to what we hoped for. given that we possess the strength to prepare each other's end, we are the masters of the apocalypse. we are in fi nity . 15 but the inability of our imagination to be equal to our unlimited power makes the latter mortally dangerous and transforms us into potential victims of what we ourselves have built: we, the men of today, are the fi rst men to dominate the apocalypse, hence we are also the fi rst to be endlessly subject to its threat. we are the fi rst titans, hence we are also the fi rst dwarves or pygmies -or whatever else we care to call ourselves, we beings with our collective deadline -we are no longer mortal as individuals, but as a group; whose existence is exposed to annulment. 16 suf fi ce it to think that it is impossible to see the bomb simply a means; an impossibility generated by the fact that if someone used the bomb… the means would not be extinguished in the purpose, but, on the contrary, the effect of the presumed "means" would put an end to the purpose. and it would not be one effect, but an unforeseeable chain of effects, in which the end of our life would be but one link among the many. 17 the gap between the power to do and the power to foresee, therefore, gives rise to the paradoxical coexistence of omnipotence and vulnerability, which exposes future humankind and the whole of civilization to the risk of extinction, thereby con fi guring the apocalyptic scenario of a 'world without man'. 18 but the problem does not stop here. indeed, if men, even when faced with the loss of foresight and projectuality caused by their own action, were capable of recognizing the reality of the danger, a change of direction could be set in motion to restore their control over their future. or, to put it in terms that allow us to return to our theme, if people felt fear in the face of the spectre of self-destruction and the enormity of the risks ahead, they would probably manage to break that promethean spiral of unlimitedness and restore sense and purpose to their action. furthermore, this is the normative premise at the basis of hans jonas's whole line of argument in favour of an ethics of responsibility. he starts from a similar diagnosis to that of anders on the drifts of technological power and the threats, for the whole living world, produced by a ' fi nally unbound prometheus' to suggest what he de fi nes as a 'heuristics of fear', as the precondition for ethically responsible action. ' […] it is an anticipated distortion of man,' he says, 'that helps us to detect that in the normative conception of man which is to be preserved from that threat […] . we know the thing at stake only when we know that it is at stake .' 19 this means that only the fear of 'losing the world' can push us to responsibly take on the problem of how to preserve it. i shall come back to the nexus between fear and responsibility later on. 20 but the problem, which anders strongly underlines -showing, unlike jonas, its complex anthropological and psychic roots -is that today we are in the presence of the unavailability of fear ; in actual fact it is paradoxically absent, due to the additional and deeper manifestation of the promethean gap which is the imbalance between knowing and feeling . indeed, there is no one who does not know what the bomb is and who does not know its possible, catastrophic consequences, but, anders adds, 'most people indeed only "know" it: in the emptiest of manners'. 21 namely, this 17 22 this asynchrony, anders points out, is something that pertains to human nature as a matter of fact. in general, in itself this is not bad, since it only shows that feeling is slower to transform. however, so to speak, it degenerates into a pathology when the gap between the faculties becomes too wide, as is happening today. as a consequence, it breaks all bonds and communication between them, 23 and reduces contemporary men to the 'most dissociated, most disproportionate in themselves, most inhuman that have ever existed.' 24 therefore, it is here, in the inadequacy of our emotional resources with respect to our productive power, that the anthropological root of our 'blindness to the apocalypse' lies. 25 and this inadequacy, which is true for all the emotions in general, concerns fear fi rst of all. everyone, in however confused a manner and in spite of the minimization strategies implemented by those who produce it, realize that the bomb is not a pure means whose function ends in the ful fi lment of a purpose, but a monstrous ' unicum ' that, together with our lives and the lives of future generations, can put an end to all purposes tout court . 26 yet, surprisingly, there is no fear : if today we were to seek out fear ( angst ),* real fear in vienna paris, london, new yorkwhere the expression ' age of anxiety ' is very much in use -, the booty would be extremely modest. of course, we would fi nd the word 'fear', in swarms even, in whole reams of publications […] . because today fear has become a commodity; and these days everyone is talking about fear. but those talking out of fear these days are very few. 27 if we are to observe our present-day situation, we could even claim that the more fear becomes the subject of talk in the newspapers and mass media, the more it is withdrawn from emotional perception and is anaesthetized by the reassuring urgency of routine and day-to-day concerns. the anaesthetizing mechanism also works in a directly proportionate manner to the enormity of the risk and the stake at play. while it may be true that at best we 22 ibid., i, 269. 23 ibid., i, 267-68. 24 ibid., i, 271-72. 25 see ibid., part iv, i, 234ff. anders underlines its historical roots, such as trust in progress that prevents man from thinking of an 'end', and above all, the con fi guration at the anthropological level of what he de fi nes as the 'medial man', whose passive and conformist action ends up removing his ability to project himself into the future, together with all sense and purpose. see ibid., part 5, i, 276ff. 26 ibid., i, 254ff. * translator's note: anders only uses one term -angst -and does not distinguish between anxiety and fear. since, however, the meaning with which he uses the term angst coincides more with 'fear' in the acceptation put forward by elena pulcini, i have decided to translate it with 'fear' so as to distinguish it from 'anxiety'. 27 ibid., i, 264. are able to imagine our own death, but not that of tens or thousands of people, and that we may be able to destroy a whole city without batting an eyelid while not managing, however, to imagine the actual, terrible scenario of 'smoke, blood and ruins', it is inevitable that we are totally incapable of perceiving the destruction of all humankind 28 : 'before the thought of the apocalypse, the soul remains inert. the thought remains a word.' 29 even though today the end of humankind has entered the sphere of possibility and even though man himself is responsible for this, the psyche removes the thought of this possibility, thus preventing fear from arising. hence, we are illiterate in fear -'analphabeten der angst' -and 'if one had to seek a motto for our age, the most appropriate thing to call it would be "the era of the inability to feel fear"'. 30 anders's diagnosis concerning the anaesthetizing of fear and the imbalance between knowing and feeling seems to fi nd a perfect correspondence in that distinctive defence mechanism that freud de fi ned as 'denial of reality'. 31 more complex and subtle than repression ( verdrängung ), which indicates the operation with which the subject pushes particular representations linked to an instinct to the unconscious, and which for freud becomes a sort of prototype of defence mechanisms, denial ( verleugnung ) causes the self, despite rationally recognizing a painful and dif fi cult situation, to prevent this reaching the emotional sphere. 32 in other words, while repression is a defence against internal instinctual demands , denial is a defence against the claims of external reality , 33 which is rationally recognized, but not emotionally felt or participated. this converts into that distinctive ambivalence of 'knowing and not-knowing' which, as has recently been 28 ibid., i, 268-69. 29 ibid., i, 269. 30 in his recent sociological valuation of the concept of 'denial', stanley cohen stresses this ambivalence, pointing this out as the most interesting side of the concept, 36 and above all the most suited to accounting for a series of phenomena that characterize contemporary reality. explicitly drawing from psychoanalysis, whose worth he acknowledges -if nothing else against the reductive simpli fi cations of cognitive psychology 37 -as more than any other approach having grasped the elusive quality of the concept of denial, cohen offers a de fi nition that fi rst of all takes into account the meaning that is more general and common to the various forms: […] people, organizations, governments or whole societies are presented with information that is too disturbing, threatening or anomalous to be fully absorbed or openly acknowledged. the information is therefore somehow repressed, disavowed, pushed aside or reinterpreted. or else the information "registers" well enough, but its implications -cognitive, emotional or moral -are evaded, neutralized or rationalized away.' 38 on the basis of this premise, cohen analyses the many forms of denial. it can occur in good faith or be deliberate and intentional; it changes in relation to the subjects' different positions, that is, whether they are victims, guilty parties or witnesses; it depends on how the object is evaluated, which can be expressed through a simple refusal to acknowledge the facts, through a different interpretation or through a rationalization that aims to prevent its psychological, political and moral implications. but the most disconcerting and problematic form, since it can affect whole cultures -as is the case today -is what makes the subjects of the denial aware and unaware at the same time, that is, placed on the threshold between consciousness and unconsciousness. here they do have access to the reality, but in such a way as to ignore it since it is too frightening or painful, or simply too unpleasant to accept. 'we are vaguely aware,' cohen says, 'of choosing not to look at the facts, but not quite conscious of just what it is we are evading. we know, but at the same time we don't know.' 39 for example, much more than the intentional denial which is often 34 ibid, 22. 35 anders, die antiquiertheit des menschen , i, 269-70. 36 cohen, states of denial . 37 'the cognitive revolution of the last thirty years has removed all traces of freudian and other motivational theories. if you distort the external world, this means that your faculties of information processing and rational decision making are faulty.' (ibid., 42) . 38 ibid., 1. 39 ibid., 5. moreover, this is the core of the freudian concept, which evidently presupposes the idea of splitting the ego ( ichspaltung ): 'freud,' says cohen, 'was fascinated by the idea that awkward facts of life could be handled by simultaneous acceptance and disavowal. they are too threatening to confront, but impossible to ignore. the compromise solution is to deny and acknowledge them at the same time.' (ibid., 27) . implemented by political actors and institutional authorities to cover up regrettable facts and unpopular decisions, this is the frame of mind that most interests us and disturbs us because it can explain the widespread and paradoxical indifference with which common people react to situations of suffering, atrocities and violence. 40 tellingly, the focus of cohen's whole and documented analysis seems to be the fi gure of the 'passive bystander' who, when faced with other people's suffering (whether this is experienced in a direct manner like a rape or episode of bullying, or is distant like genocide or torture), defensively withdraws from all involvement, pretending not to see and not to know, inhibiting emotional reactions, minimizing the event's capacity or changing channel if the information is transmitted through mass media images. hence the bystander withdraws from facing up to painful and embarrassing situations and avoids all possible mobilization. therefore, cohen seems, quite rightly, to rediscover denial above all as a reaction of defence in the face of other people's suffering where this assumes such proportions as not to be acceptable by the psyche. as a consequence, he fi nds it to be the root of the emotional indifference that today seems to be permeating contemporary societies. nevertheless, as we have seen, anders's re fl ection allows us to grasp another aspect of denial that sharpens its paradoxical nature, since it concerns the tendency to ignore, wipe out or minimize something that not only concerns other people's destinies, but that threatens our own lives: like in the exemplary case of denying the global challenge par excellence , the nuclear risk. consistent with anders's diagnosis, a few decades ago the psychoanalysis of war had already re fl ected on the radical changes caused by the nuclear threat with respect to the traditional forms of war con fl ict, and hence explained, more or less indirectly, the psychic roots of this speci fi c case of denial. while underlining the abstract or phantasmal nature of the danger at the objective level -due to the invisibility and intangibility of nuclear weapons, the distance of the target, as well as the bureaucratic 'normality' of those who hold the actual decision-making powersome authors have singled out the unprecedented nature of the nuclear con fl ict in its split and autonomization from the individual's instinctual sphere. 41 that is, unlike traditional war, based on mobilizing aggressive instincts, nuclear war (its destructive potential) appears as a mechanical event, or rather, a psychologically unreal event, in which the 'enemy' himself, far from being the object of projective dynamics, becomes an inanimate abstraction with whom all emotional bonds are lost. 42 this sort of 'dehumanization' of war, which affects the relationship with the other and the relationship with oneself to the same extent, thereby producing its 40 'the grey areas between consciousness and unconsciousness are far more signi fi cant in explaining ordinary public responses to knowledge about atrocities and suffering' (ibid., 6). 41 'devitalization', 43 is at the root, together with the enormity of the risk and the impossibility to 'think the unthinkable', 44 of the denial of the danger, which immunizes individuals from emotional involvement, and, therefore, from true awareness. it is telling that, in addition to denial, martin wangh spoke of a 'narcissistic withdrawal', 45 as he alluded to the entropic and self-defensive strategy of individuals reduced to passive and indifferent 'spectators' of events. individuals who, with respect to events, preclude any form of effective reaction and thus inhibit the insurgence of fear at the outset. i will return to the 'spectator phenomenon' shortly. 46 as i have already hinted, this phenomenon is one of the most disturbing pathologies of contemporary individualism. first, however, it is interesting to dwell on one of the -so to speakmore active variants of denial, which consists not only of withdrawal from a reality that is uncomfortable or painful for the psyche, sheltering in a sort of emotional indifference, but of lying to ourselves in order to believe something that does not respond to our rational evaluations, but to our desires. this is self-deception , a defence mechanism that has tellingly been de fi ned as 'the most extreme form of the paradox of irrationality'. 47 without going into the (at times muddled) analytical controversies relating to a concept that is without doubt slippery and problematic, 48 we can, however, try to sum up the characteristics -shared by many authors -which prove fruitful in further extending the picture relating to the metamorphosis of fear in the global age. self-deception is what pushes individuals to form a belief that contrasts with the information and proof at their disposal, since their desires end up interfering with their vision of reality and cause them to act in a different way from what their rational judgement would suggest. in other words, it consists of believing something because one desires it to be true, 49 hence it converges, despite some differences, with 43 martin wangh speaks of 'dehumanization' and 'devitalization' (meant as the impoverishment of the ability to feel) in 'narcissism in our time: some psychoanalytic re fl ections on its genesis," psychoanalytic quarterly 52 (1983). 44 the allusion is to the text by herman kahn, thinking about the unthinkable (new york: horizon press, 1962). 45 martin wangh, "the nuclear threat: its impact on psychoanalytic conceptualizations," psychoanalytical inquiry , no. 6 (1986). 46 the expression ( zuschauer-phänomen ) is by martin wangh, "die herrschaft des thanatos," in zur psychoanalyse der nuklearen drohung. vorträge einer tagung der deutchsen gesellschaft für psychotherapie, psychosomatik und tiefenpsychologie , ed. carl nedelmann (göttingen: verlag für medizinische psychologie, 1985). 47 david pears, "the goals and strategies of self-deception," in the multiple self , ed. elster, 60; giovanni jervis, fondamenti di psicologia dinamica (milan: feltrinelli, 1993) and massimo marraffa, "il problema dell'autoinganno: una guida per il lettore," sistemi intelligenti , no. 3 (1999): 373-403. 48 '[…] self-deception,' davidson says, 'is a problem for philosophical psychology. for in thinking about self-deception, as in thinking about other forms of irrationality, we fi nd ourselves tempted by opposing thoughts.' (donald davidson, "deception and division," in the multiple self , ed. elster, 79). 49 ibid., 86. the dynamic of wishful thinking. 50 like denial, meant in its pure form, so to speak, self-deception implies ichspaltung , no matter what name may be given to what freud identi fi ed as the splitting of the ego. 51 finally, like denial, it is an ambivalent phenomenon since it acts in that threshold between consciousness and unconsciousness which, as cohen stresses in this case too, creates a paradoxical situation of knowing and not-knowing. 52 but while denial appears, as we have seen, effective in explaining the lack of perception and the anaesthetizing of fear in the face of the nuclear threat, selfdeception can prove pertinent in order to understand the complex emotional response that individuals give to the other global risk already brought up above: that is, the twofold environmental risk of global warming and the depletion of the ozone layer, which by no means seems to generate that mobilization of the whole of humankind which it would instead -urgently -require. 53 from this point of view, the recently proposed de fi nition of 'global risks in the making' or 'potentially global' risks, which tends to distinguish them from the global risk par excellence represented by nuclear power, 54 can prove to be extremely useful in explaining the however blurred difference in the subject's reaction and in further enlightening the phenomenology of fear. the inde fi nite nature that without doubt also pertains to the nuclear risk is greatly stressed here, due to the fact that global warming and depletion of the ozone layer have wider margins of uncertainty created by their inertial nature, the impossibility to measure and foresee their future development, and therefore to calculate with certainty, together with their possible effects, the last deadline for possible countermeasures. their ungraspable and invisible nature, further fuelled by the dif fi culty to point the fi nger of blame mean that, in spite of the alarming international reports on the climate and reliable scienti fi c forecasts on the devastating future damage, moreover given increasing mass media coverage, individuals mostly seem 50 in paradoxes of irrationality (in richard a. wollheim and james hopkins, eds., philosophical essays on freud , (cambridge: cambridge university press, 1982)), davidson upholds that in wishful thinking desire produces a belief without providing any proof in its favour, so that in this case the belief is evidently irrational. however, he underlines the differences between self-denial and wishful thinking: unlike the second, the fi rst requires the agent's intervention, that is, the agent has to 'do' something to change his way of seeing things; in the second the belief always takes the direction of positive effect, never of negative, while in the fi rst the thought that it triggers can be painful (see 'deception and division', 85ff.). 51 in this connection pears speaks of 'functional insulation', "goals and strategies of self-deception", 71; davidson speaks of 'boundaries': '[…] i postulate such a boundary somewhere between any (obviously) con fl icting beliefs. such boundaries are not discovered by introspection; they are conceptual aids to the coherent description of genuine irrationalities.' "deception and division", 91-92. on self-denial and splitting of the ego, see herbert fingarette, self-deception (london : henley-routledge, 1969) . 52 see cohen, states of denial , 37ff. 53 it is important to point out that the second problem (the one relating to the risk of ozone layer depletion) nevertheless found some solutions as of the montreal protocol in 1987, made possible due to the fact that they did not require costs or relinquishments in terms of economics or lifestyle. 54 d'andrea, "rischi ambientali globali e aporie della modernità". to fail to suitably perceive the phenomenon. instead, it is often shrugged off with detached irony towards the excessive catastrophism, with resigned declarations of impotence, or the expression of enlightened trust in the capacities of technology to repair the situation. 55 in other words, despite being rationally known and recognized, the risk does not produce such emotional involvement as to give rise to effective answers. at most it produces a widespread and generic feeling of anxiety which ends up imploding, sucked in by the much more real worries of everyday life. the causes of this paradoxical situation can be traced fi rst of all to within the same dynamic of fear of which, as i will recall, hobbes's diagnosis had grasped an essential aspect. namely, fear as a necessary and vital passion that allows us to respond to the immediate danger (of death) loses its ef fi cacy when the danger, and the damage it could cause, are shifted to the future, that is, when a time gap inserts itself between the present action (based on destructive passions) and its possible consequences. thus all certainty and inexorability are taken away from the evil, enabling individuals to imagine it as a remote and avoidable possibility, for which it makes no sense to mobilize themselves immediately. in other words, in this case, fear does not manage to overcome the passions of the present. hobbes's intuition is all the more valid in the case of global risks, whose possible damage is even more remote and does not concern current individuals, but future generations. that is, fear does not have the strength to change present action (and therefore the underlying desires and passions) when the damage that this action can cause is not an evil for ourselves but for 'others': anonymous, generic and distant in time. in short, by weakening fear, the future nature of the damage makes it easy for essentially selfpreserving and narcissistic individuals to deceive themselves as to the actual entity of the risk and therefore to minimize or deny the possible consequences. in this case, the aim is not so much for individuals to defend themselves emotionally from events that are too painful to bear (like in the case of nuclear con fl ict), but to carry on with a manner of acting that allows them to legitimize and satisfy their current desires, preserve their lifestyles and not lose consolidated privileges. to once again recall the pathologies of the global self, we could say that the acquisitive voracity of homo creator , orientated towards unlimited growth, combines with the parasitic bent of a consumer individual anchored solely to the present, to prevent access -through the cunning of self-deception -to a correct perception of the catastrophic effects of climate change, global warming, the greenhouse effect and depletion of the ozone layer. this appears all the more paradoxical where these effects start to be dramatically visible: tropicalization of the climate, deserti fi cation, destruction of the ecosystem, lethal viruses and infective diseases are no longer only remote possibilities but the disturbing proof of environmental risks. by now scattered all over the planet, 56 they affect whole geographical areas and populations, damaging the illusion of individuals and states' immunity more and more. indeed, despite not just abstract information and forecasts, but a more and more invasive state of affairs that is starting to concern them at close quarters, guaranteed and supported by the instrumental interests of local politics and the global economy, individuals prefer to deceive themselves in order not to pay the costs of relinquishing their current desires, assets and pleasures; further eased, in this self-defensive operation, by the morally innocent, innocuous and banally everyday nature of the action that produces the risks. 57 moreover, the absence of a 'productive' fear, inhibited by denial and self-deception, is not belied by the cyclical outbursts of panic and collective hysteria in the face of the sudden appearance of threats (as has always been the case, from chernobyl, to sars and bird fl u). on the contrary, the absence and the excess of fear are nothing but two sides of the same coin, 58 the two extreme and 'unproductive' manifestations of what i de fi ned as global fear . both denial and self-deception leave individuals in the passive position of spectators of events. thus they are enclosed in the immunitarian circuit of a self-defensive and self-preserving individualism which anaesthetizes fear and is incapable of converting into effective action, practice or political participation. alongside the two extroverted pathologies, so to speak, of unlimited individualism, represented by the insatiable voracity of the consumer individual and the omnipotence of homo creator , appears a third, paradoxically introverted con fi guration, namely a passive and impotent individual, who helplessly watches the destructive effects of his own action, over which he seems to have lost all capacity for orientation and control. against the loss of objective spaces of protection and security, increasingly eroded by the global diffusion of the risks, he seems to seek shelter, as i have already hinted , 59 in a sort of interior immunity , entrenching himself in the emotional indifference that is just one of the many manifestations of narcissism. in addition, the yearning for immunity becomes more tenacious and obstinate the more it is felt to be ineffective and illusory. thus a new condition is outlined, which to recall the metaphorical fi gures proposed by hans blumenberg in his shipwreck with spectator , 60 is neither the premodern and 'lucretian' condition of the spectator watching the shipwreck from a safe place, sheltered from the danger, nor the modern and 'pascalian' condition of being the actors of our own lives, ' être embarqués ', involved in the things of the world and ready to put ourselves at stake fi rst of all by recognizing the constitutive precariousness of the human condition and accepting the very risk of existence. while modernity had rati fi ed the decline of the spectator fi gure, and enhanced the moments of practice and action, involvement and commitment; and while late modernity had radicalized his condemnation by emphasizing the need to expose oneself to risk and accept the uncertainty and fl uidity of the human condition, 61 the global age seems to be objectively bringing the spectator up-to-date, which nevertheless coincides with a deep and disturbing change with respect to the fi gure of the lucretian wise man. the erosion of boundaries and disappearance of an 'elsewhere'redrawing global space, cancelling out the distinction between inside and out -is turning into the loss of free areas from where the shipwreck can be observed. at this point, due to the end of every real guarantee of immunity, deprived of the possibility of a safe harbour where he can feel sheltered from the world's dangers, the global self withdraws into the only space apparently able to protect him from events and threats that he is not able to deal with: namely, the wholly interior space of an emotional indifference, an anaesthetizing of emotions , generated by implementing sophisticated and for the most part unconscious defence mechanisms. in other words, the spectator fi gure is undergoing a process of interiorization , which replaces the spatial distance from the shipwreck and the contemplative safety of the lucretian subject with the apathetical extraneousness and obstinate blindness of he who refuses to recognize the very risk of the shipwreck, and encloses himself in the entropic space of an inert solitude. moreover, the spectator phenomenon seems to pervade the whole social structure, due to the spectacularization of reality that, as jacques debord had already masterfully diagnosed a few decades ago, deeply upsets the very nature of social relations. 62 by denouncing the erosion of the boundaries between real and virtual and the pervasive power of images (mass media images fi rst of all), and by diagnosing life's 'total colonization' by commodi fi cation processes and the indistinctive overlapping of true and false as the effects of the 'society of the spectacle', debord had indeed grasped the spectator fi gure as the symptom and symbol of a new form of alienation that invades the individual's whole relationship with the world. passiveness and submission to the totalitarianism of images, prioritization of appearance, loss of contact with one's desires and genuine needs, atomism and isolation are among the most evident and disturbing characteristics of the spectator-individual, who thus ends up losing all capacity to be involved and to grasp reality. in short, the emotional indifference in which individuals shelter in order to cancel out the awareness of the risks surrounding them, unconsciously implementing powerful defence mechanisms, seems to be a sort of inevitable outcome of a widespread anthropological condition. or rather, it seems to be the extreme form of a general tendency towards apathy and inertia, produced by a spectacular society that empties reality of its contents and thus deprives individuals of pathos and action. suf fi ce it to think of the de-realizing effects, with respect to the effective drama of events, produced by mass media images (for example the fi rst gulf war), 63 or the narcotizing addiction that they cause to dangers and catastrophes of all kinds (from tsunamis to sars). the images deprive events of the fl esh and blood of the experience and neutralize them in the aseptic and equalizing space of the screen. however, the problem today is no longer the subject's passivization and atomization alone, nor his a-pathetical detachment from reality: aspects which, moreover, sociological re fl ection on narcissism had already underlined some time ago, and to which the most recent and sagacious sociological diagnoses do not fail to draw attention. 64 the problem, as we have seen, regards above all the negation of reality and the possible destructive effects of this denial on the very survival of individuals and the whole of humankind. by withdrawing into the immunitarian space of a selfdefensive apathy, the global spectator performs a dangerously illusory operation which precludes the possibility to perceive and understand what the unprecedented risk of the global age is: namely, that he himself is the potential victim of events from which there is no shelter, or rather, from which there is no other possible shelter than active and universal mobilization. 65 while it may be true that the hallmark of global challenges is that they cross boundaries and no perimeter can be drawn around or circumscribe them, it is also true that everyone, in every corner of the planet, is always potentially exposed to their effects, that everyone is always potentially a victim of a shipwreck which, for the fi rst time, could affect and sweep away humankind and all living beings. by anaesthetizing fear, the denial (and self-deception) strategy paradoxically ends up betraying the very same purpose that it had been implemented for: namely, self-preservation. or rather, in order to pursue an entropic and defensive selfpreservation that preserves them from all emotional and active involvement, not only are individuals undermining the quality of their lives, but the very preservation of humankind and the world. 63 see antonio scurati, televisioni di guerra. il con fl itto del golfo come evento mediatico e il paradosso dello spettatore totale (verona: ombre corte, 2003), who observes how the increase in media exposure of the war phenomenon corresponds to a lesser ability, on the part of the spectator, to grasp its reality. as a result, on the part of the citizen there is less possibility to decide and act. in other words, the 'total visibility' offered by the television medium corresponds, in an only apparent paradox, to the blindness and impotence of the 'total spectator'. 64 this unwillingly nihilistic outcome could perhaps be interpreted as a radical and extreme manifestation of the immunitarian paradigm recognized as the very emblem of modernity, owing to which the preservation of life is paradoxically turned around into its negation. 66 however, what i would like to stress, to go back to anders's diagnosis, is the fact that -in this case at least -this worrying reversal originates in the pathologies of feeling and the denial of fear, which prevent individuals from recognizing their paradoxical condition of spectators and victims at the same time. denial, however, is just one of the unproductive metamorphoses of fear in the global age, and only one of the strategies that the global individual uses to contrast the anxious perception of new risks. denial sums up the individualistic and implosive response to the inde fi nite and unintentional threats produced by techno-economic globalization. in parallel to this there emerges, as i had mentioned, another defence strategy, which responds to what is perceived as the second, fundamental source of danger, essentially generated by economic-cultural globalization: that is, defence against the other . this strategy is specular to the fi rst since it converts more into an excess rather than an absence of fear, and i have suggested de fi ning it as communitarian and explosive . 67 it is based on reducing insecurity and inde fi niteness through the defence mechanism of projection : namely, the fear is displaced onto indirect and specious objects since these appear easier to de fi ne and identify. many of the ethnoreligious con fl icts that are traversing the planet can at least in part be traced back to this basic defence mechanism which converts inde fi nite anxiety into de fi nite fear. in this case too, we are dealing with a strategy that is anything but new since, as we will see, it results in the classic mechanism of building a 'scapegoat'. however, the novelty lies in the fact that, like in the denial strategy, this strategy seems to be resulting in substantial ineffectiveness . if, as suggested to us by rené girard's enlightening diagnosis, the fundamental goal of creating scapegoats has always been, since the origins of civilization, to keep check on and resolve violence in defence of a given community, today we are instead faced with an escalation in violence which attests to the substantial failure of the scapegoat dynamic. through a fascinating thesis that i can only brie fl y recall here, 68 girard claims that in truth this loss of effectiveness has distant roots, since it coincides with the end of the processes which made violence ritual and sacred, and with the revelation of the 66 see esposito, immunitas . 67 here there is a generic allusion to bauman's 'explosive communities' in liquid modernity . 68 of great use for the issues that follow is the essay by stefano tomelleri, "il capro espiatorio. la rivelazione cristiana e la modernità," studi perugini , no. 10 (2000): 147-57. victimage mechanism brought on by the advent of christianity. 69 in other words, while archaic societies had entrusted the rite of sacri fi cing the scapegoat with the function of providing a remedy to internal violence in order to found and preserve social order and peaceful coexistence among men, the revelation of christ radically damaged this mechanism since, by disclosing the victim's innocence, for the fi rst time it made people aware of the victimizing and persecutory dynamics. by unmasking the nexus between violence and the sacred, the christian message led to the breakdown of the mythical-ritual universe, and placed people before the unavoidable truth of their violence. thus it weakened the possibility of resolving the violence through the sacri fi cial mechanism and opened totally new scenarios, affected by a fundamental ambivalence. on one hand, by depriving men of all external justi fi cation for their violence, the christian revelation of the victim's innocence opened up the possibility of renouncing the scapegoat logic and resolving the problem of the social bond, without any exclusion or sacri fi ce; on the other hand, in the absence of ritual antidotes and their power to create order, it exposed men to the spreading of violence and the persistence -in more ambiguous, disguised and clandestine forms -of the victimage mechanism. that this second scenario is the one which, unfortunately, has ended up prevailing is manifestly undeniable; and, paradoxically, it can be pinpointed as originating above all in modernity. while it may be true that modernity -the time of rights, democracy and equality -seems to offer the possibility of transforming violence into 'soft', peaceful and even emancipatory forms of competition and rivalry, it is also true that, for the same reasons, it can provide a breeding ground which favours the heightening of violence. indeed modernity produces an ampli fi cation of the mimetic dynamic that girard recognized as the constitutive source of violent con fl ictuality among men. as has been underlined, the same equality that, à la tocqueville, can be interpreted as a loss of differences, frees the mimetic desire, which becomes unlimited 70 and inevitably exacerbates rivalry among people. in other words, in a society of equals the desire to be according to the other which pushes the mimetic actor to see the other as model and rival at the same time, triggers a spiral of competitive comparison. even the smallest difference becomes the opportunity for resentment, envy and hate, and can always provide the opportunity for violent clashes. while on one hand democratic indifferentiation and, we could add, narcissistic and postmodern intolerance towards every difference -which tocqueville had prophetically diagnosed 71 -provoke the continuance of rivalry and con fl ict, on the other hand the sacri fi cial dynamic, to which premodern societies had entrusted the function of keeping check on violence, seems to have lost its traditional ef fi cacy due to its irreversible disclosure. this means that modern and contemporary societies are exposed to a radical 'crisis of the sacri fi cial system' which, since it is impossible to fi nd a solution in the scapegoat mechanism, can result in a multiplication of violence and its manifestation in increasingly crude and destructive forms. 72 the loss of the victimage mechanism's ef fi cacy, due to the deritualization process, does not equate to its disappearance, however. on the contrary, girard once again observes that phenomena of 'sacri fi cial substitutions' reappear 'in a shameful, furtive, and clandestine manner' so as to avert moral condemnation (and selfcondemnation). 73 they take on the shape of psychological violence which is easier to conceal, or they re-explode in the exacerbated form of immolating victims to evil ideologies, as was the case of the genocides in the twentieth century. these mechanisms continue in our world usually as only a trace, but occasionally they can also reappear in forms more virulent than ever and on an enormous scale. an example is hitler's systematic destruction of european jews, and we see this also in all the other genocides and near genocides that occurred in the twentieth century. 74 of course the reference to the nazi genocide is not random, but extremely emblematic of the modern and contemporary reappearance of the victimage mechanism in spite of its disclosure. a fi rst formulation of this can be found in the diagnosis of totalitarianism that franz neumann was already suggesting in the 1950s, as he traced its psychic origins back to the transformation of fear into 'persecutory anxiety'. 75 every time, neumann says, over the course of history a particular social group (whether it can be de fi ned on the basis of class, religion or race) feels threatened by objective dangers which, together with material survival, compromise its prestige and identity, the deriving anxiety is displaced onto groups and people, who are given the requirements ad hoc , 76 and the guilt made to converge on them. if we are to take up the freudian distinction between 'realistic anxiety' and 'neurotic anxiety ', 77 neumann shows how fear and uncertainty are transformed into persecutory anxiety through the projective and hence specious creation of an enemy who becomes the subject of hate and aggression. as a result, the masses threatened with disintegration can rediscover their internal cohesion. in the case of nazism and the persecution of the jews, political and ideological manipulation linked up to this social dynamic, took advantage of the mass anxiety and pushed the masses towards 'caesaristic' and regressive identi fi cation 78 with a leader libidinally attributed the task of resolving the anxiety by expelling the evil and its presumed carriers. 79 by recognizing the victimage mechanism as originating in the persecutory transformation of anxiety, neumann allows us to see its emotional roots, which girard evidently considers less essential for his so-to-speak ontological diagnosis of violence. however, at the same time, while neumann particularly stresses the totalitarian outcomes of the scapegoat dynamic, 80 girard underlines its persistence in 'all the phenomena of nonritualized collective transference that we observe or believe we observe around us.' 81 although deritualized -and indeed all the more violent for this precise reason -the victimage mechanism continues to act in the same modern democratic societies in all creeping and disguised phenomena of exclusion and discrimination, or in the cyclical explosions of reciprocal aggression and disdain that are fuelled by identity con fl icts: we easily see now that scapegoats multiply wherever human groups seek to lock themselves into a given identity -communal, local, national, ideological, racial, religious, and so on. 82 evidently, here we are coming back to the topic of identity con fl ict which, as we have seen, is proliferating inside and outside the west, bringing the scapegoat strategy back up-to-date: a strategy which becomes all the more aggressive the more the perception of the threat grows in a global society. by eroding territorial and cultural boundaries, globalization is producing, fi rst of all in western societies, a disturbing proximity of the other. as a result, the other can increasingly be identi fi ed with the simmelian fi gure of the 'stranger within', who challenges the order and cohesion of a given community through a swarming and liminal presence that is felt, as suggested 78 neumann stresses the regressive nature of this identi fi cation mechanism for the very masses who implement it, since it involves alienation and the relinquishment of one's self: 'since the identi fi cation of the masses with the leader is an alienation of the individual member, identi fi cation always constitutes a regression'. ( anxiety and politics , 277). 79 'caesaristic identi fi cations may play a role in history when the situation of masses is objectively endangered, when the masses are incapable of understanding the historical process, and when the anxiety activated by the danger becomes neurotic persecutory (aggressive) anxiety through manipulation.' (ibid . , . 80 it is interesting to see how neumann indeed also alludes to the unconscious nature of the persecutory dynamic: 'hatred, resentment, dread, created by great upheavals, are concentrated on certain persons who are denounced as devilish conspirators. nothing would be more incorrect than to characterize the enemies as scapegoats […] for they appear as genuine enemies whom one must extirpate and not as substitutes whom one only needs to send into the wilderness.' (ibid., 279) . 81 girard, i see satan fall like lightning , 160. 82 ibid., 160. by mary douglas, as potentially contaminating. coming forth in response to the siege of a hybrid and unstemmable multitude that is penetrating the protected spaces of our identity citadels is the ancestral fear of a 'contamination' endangering the need for 'purity' upon which, douglas says, every culture and civilization builds its reassuring separations and classi fi cations. 83 the other (the stranger, he who is different, the migrant, the illegal immigrant) becomes the target upon whom to displace our fears, upon whom to project a persecutory anxiety that transforms him into the person responsible for the dangers threatening a society that is increasingly deprived of the traditional control structures. 84 hence this enables that blaming process which is indispensable for social cohesion and which, however, the anarchic and anonymous logic of globalization seems to be progressively eroding. 85 but since it is no longer possible to rely on ritual expulsion practices or strategies to con fi ne the other to a spatial and territorial elsewhere clearly divided by a de fi nite boundary that traces the separation between an inside and an outside, the exclusion mechanism becomes interiorized and acts at an eminently symbolic level. the exclusion dynamic, as has been underlined, is shifted into the conscience: 'defence and exclusion, no longer possible towards the outside, will be shifted into the conscience, the imagination, the social mythologies and into the self-evident that these hold up.' 86 thus immunity is ensured through dehumanization processes that transform the stranger within (the metoikos ) into an 'inside being' in such a way that he remains an 'outside being' all the same. 87 all this can take place in the insidious and hidden forms of psychological violence and everyday discrimination towards those who have crossed the territorial boundaries of a state and broken the taboo of distance and separation, therefore representing a constant challenge to consolidated privileges and to the 'purity' of identity. or it can occur through cyclical collective mobilization against the weak and marginalized in the attempt to deal with insecurity by displacing the fear onto problems of personal safety, which politics does not then hesitate to exploit, in selflegitimation, in the name of defending public order. 88 but, as we have already seen, it can also convert into a real and proper 'attack on the minorities', in which it is perhaps legitimate to recognize, as suggested by arjun appadurai, the distinctive form of violence spreading to the global level. when global insecurity is added to the delirious fantasy of national purity which appadurai de fi nes as an 'anxiety of incompleteness', the majorities in every single state whose hegemony is threatened tend to transform into 'predatory identities'. their aim becomes to defend the purity of the ethnos by eliminating the element of disturbance represented by the 'minor differences'. the minorities 'are embarrassments to any state-sponsored image of national purity and state fairness. they are thus scapegoats in the classical sense.' more speci fi cally in the global age they 'are the major site for displacing the anxieties of many states about their own minority or marginality (real or imagined) in a world of a few megastates, of unruly economic fl ows and compromised sovereignties.' 89 from iraq to ex-yugoslavia, from indonesia to chechnya, from palestine to rwanda, to the emblematic case of the clash between hindus and muslims within a modern democracy like india, the victimage mechanism seems to reassert itself with a fresh violence that tellingly -testimony to the obsession with purity at its origin -seems to repeat itself in particular towards the body . indeed, as appadurai underlines by taking on douglas's perspective, the body becomes subject to unheardof violations and atrocities (bodies massacred, decapitated, tortured, raped) in view of punishing the minorities for the fact that they 'blur the boundaries between "us" and "them," here and there, in and out, healthy and unhealthy, loyal and disloyal, needed but unwelcome.' 90 nevertheless, it is precisely this obsessive, punitive and puri fi catory nature that announces the danger that the violence may assume an unstemmable drift. 91 far from producing a stop to the violence, the scapegoat strategy causes its proliferation, through a sort of perverse up-the-ante that seems to bring the brutality of archaic practices, such as sacri fi ce, and of the starkest materiality back inside the abstract and impersonal space of globalization. 92 but that is not all. today the spiral of violence is further fuelled by a new factor that upsets the logic -to date essentially one-way -of the persecutors-victims relationship. what happens, unlike for example the emblematic case of nazism, is that the other tries to overturn his position as victim, and in turn becomes the persecutor, giving rise to a dynamic of hostility and aggression that potentially becomes unlimited owing to its reciprocal and specular nature. suf fi ce it to think of islamic terrorism and the projection it puts upon the west as the image of the other and evil, against which, by fuelling passions of resentment , 93 a compact and endogamous us is condensed together and built. indeed this proves the fact that the scapegoat, as girard warns, is not only necessarily embodied in the weak and oppressed but also in the rich and powerful. 94 hence, in the grip of dehumanization on one hand and demonization on the other, 95 the world becomes a theatre, through the reciprocal invention of an enemy, of an escalation in violence that has much to do with the persecutory metamorphosis of insecurity and anxiety and very little to do with a presumed 'clash of civilizations'. 96 shifted to the inner self, the victimage mechanism continues to act, hidden from view. nonetheless, it ultimately becomes ineffective since it fails in its original purpose to resolve the fear and keep a check on violence. orphaned of ritualization processes and deprived of an 'elsewhere' that permits the other's spatial and territorial exclusion, the construction of the enemy/victim generates forms of identity cohesion that are as aggressive as they are regressive, fuelled by a reciprocal persecutory projection. far from restoring cohesion and security to a given community, the scapegoat dynamic gives rise to endogamous and reciprocally exclusive processes of building an us , whose foremost and manifest effect is to form what i have de fi ned as immunitarian communities : 97 whether they are the 'voluntary ghettoes' and 'communities of fear' that explode cyclically in a west frightened by the siege of the other and anything but free from regressive phenomena, or ethno-religious communities entrenched around the obsession of identity and homogeneity, willing to reactivate atrocious forms of excluding the other, or lastly global communities that come together around the war/terrorism polarization. the metamorphosis of fear in the global age therefore seems to con fi rm, at the emotional level, the pathological split between an unlimited individualism and an endogamous communitarianism , which originates in the implementation of defence mechanisms leading to not only the polarization of an absence and excess of pathos , but also, it needs to be stressed, in their substantial inef fi cacy . on one hand, the denial of fear, we have seen, pushes individuals towards forms of apathy and narcissistic entropy that prevents them from recognizing the new risks produced by global challenges. as a consequence, this produces the individuals' incapacity to perceive their unprecedented condition of spectators and potential victims at the 94 same time, and fuels the illusion of immunity: which means that in the name of entropic self-preservation we end up delivering the whole of humankind to the danger of self-destruction. on the other hand, the persecutory conversion of fear generates perverse and endogamous forms of alliance and solidarity, which thereby result in the reactivation of destructive communities driven by 'primordial loyalties'. this gives rise to the explosive drift of identity con fl icts and to an unlimited escalation of violence at the planetary level. between self-obsession and us-obsession , as the specular polarities of the same immunitarian strategy, we run the risk of not grasping the chance 98 that the global age could actually be capable of offering through the very transformations that it produces and the very challenges that it contains. on one hand, as we will see, the risks that are bearing down on humankind for the fi rst time mean we can think of the latter as a new subject, as a set of individuals linked by their common vulnerability and weakness . therefore, they are able to take care of the world in the sense of the planet, the 'loss' of which would coincide with the disappearance of the only dwelling of living beings that we know of. on the other hand, the multiplication of differences and the slide of the idea of 'other' towards the notion of 'difference', which can neither be assimilated nor expelled into an elsewhere, for the fi rst time makes it possible to rethink the social bond as the solidaristic coexistence of a plurality of individuals, genders, cultures, races, religions, capable of forming a 'world', à la arendt, since they are capable of recognizing not only the necessity but also the potential vitality of reciprocal contamination . these real possibilities are, however, only a chance. insofar as it is a chance, the subjects have the task of knowing how to grasp it. to recall a successful suggestion by andré gorz, we could say that to pro fi t from the chance in the fi rst place means 'to learn to discern the unrealized opportunities which lie dormant in the recesses of the present' 99 ; or, in a word, to lay a wager on the ability to build alternative scenarios and create possibilities that may not yet have been taken up but are still latent. 98 the expression is inspired by georges bataille who, as already remembered above, proposes the idea of chance meant as the 'possibility of openness', see on nietzsche (london: athlone, 1992), originally published as "sur nietzsche," in oeuvres complètes, vol. 6 (paris: gallimard, 1976). 99 gorz, reclaiming work , 1. originally published as des choses cachées depuis la fondation du monde we haven't given up having scapegoats, but our belief in them is 90 percent spoiled. the phenomenon appears so morally base to us, so reprehensible, that when we catch ourselves "letting off steam" against someone innocent, we are ashamed of ourselves originally published as je vois satan tomber comme l'éclaire democratic and authoritarian state neumann says, there must always be a core of truth that makes this choice particularly dangerous: so in the case of the jews, the core of truth is given by their being 'concrete symbols of a so-called parasitical capitalism, through their position in commerce and fi nance on this see part ii purity and danger. an analysis of concepts of pollution and taboo mary douglas underlines that risk itself becomes a resource at the moral and political level and speaks of a 'forensic theory of danger': 'disasters that befoul the air and soil and poison the water are generally turned to political account: someone already unpopular is going to be blamed for it.' ( risk and blame , 5) risk and blame appadurai continues, 'are metaphors and reminders of the betrayal of the classical national project. and it is this betrayal -actually rooted in the failure of the nation-state to preserve its promise to be the guarantor of national sovereignty -that underwrites the worldwide impulse to extrude or to eliminate minorities originally published as orrorismo fear of small numbers , chap. 3 again underlines the nexus between the abstract logic of globalization and the brutality of physical violence 519-33; for an interesting treatment of the topic see stefano tomelleri key: cord-321036-nqg9tz4s authors: mascret, nicolas title: confinement during covid-19 outbreak modifies athletes’ self-based goals date: 2020-09-07 journal: psychol sport exerc doi: 10.1016/j.psychsport.2020.101796 sha: doc_id: 321036 cord_uid: nqg9tz4s because achievement goals are context-specific, the study first investigated the evolution of two achievement goals of 697 regular athletes, namely self-approach goals (improving oneself) and self-avoidance goals (avoiding regression), before and during the confinement situation and the physical exercise restrictions due to the covid-19 outbreak. secondly, we sought to examine the potential predicting role of self-approach and self-avoidance goals on athletes’ intention to exercise during confinement, while self-avoidance goals were usually not related to this outcome in a more traditional context. using a retrospective correlational design, the results of repeated measures anova highlighted that self-approach goals scores decreased while self-avoidance goals scores increased and became the athletes’ goals with the highest score during confinement. the results of hierarchical regression analyses showed that self-approach and self-avoidance goals were both found as positive predictors of intention to exercise during confinement. this study reinforces the assumptions that (a) a specific achievement setting encourages the adoption of different achievement goals (which was identified here with regular athletes in an unusual context of confinement), (b) self-avoidance goals are not always maladaptive, and (c) shifting among multiple goals according to the requirements of the situation may be beneficial. pol & kavussanu, 2011). the question arises whether the confinement situation and the 1 physical exercise restrictions due to the covid-19 outbreak may impact the achievement goals 2 adoption of regular sportspeople, especially the adoption of avoidance-based goals which 3 focus on failure (elliot et al., 2011) . answering this question was the first aim of the study. 4 self-approach (improving oneself) and self-avoidance (avoiding regression) goals were 5 investigated in the present study because the strong constraints on physical exercise due to 6 confinement could promote self-avoidance goals. in contrast, these goals are usually 7 underrepresented among all athletes in a more conventional sport context because they are 8 likely to be prevalent among older athletes on the downside of their sports career (mascret, 9 elliot, & cury, 2015) . 10 the second aim of the study was to examine the potential predicting role of self-11 approach and self-avoidance goals on athletes' intention to exercise during confinement. to 12 date, no study has investigated this issue even before confinement. but self-based goals were 13 previously included in broader goals called mastery-approach goals (striving to develop 14 competence through task mastery and personal improvement) and mastery-avoidance goals 15 (not doing poorly relative to task demands or one's own performance trajectory). the recent 16 review of lochbaum, zanatta, and kazak (2020) highlighted that mastery-approach goals 17 were positively related with intention to exercise (and many other positive outcomes) whereas 18 mastery-avoidance goals were unrelated with intention to exercise, and often associated with 19 negative outcomes such as worry or reduced enjoyment (gardner, vella, & magee, 2017). 20 similarly, athletes' self-avoidance goals (avoiding regression) were negatively related with 21 happiness (briki, 2019). we wondered, however, whether self-avoidance goals may for once 22 be positive predictors of athletes' intention to exercise during confinement because they could 23 be more congruent with this particular and temporary context. a total of 697 french participants (356 men, 341 women, m age = 31.4 years, sd = 2 10.19) voluntarily filled out the questionnaire. sample size was based on the maximum 3 number of participants that could be recruited during the week of data collection. participants 4 had to be of legal age (18 years old in france) and had to practice sport or physical exercise 5 on a regular basis before the confinement due to covid-19 (m time of practice = 7.15 hours per 6 week, sd = 3.53), assessed using a single item "on average, how many hours per week did 7 you exercise before the start of confinement?". two hundred and seventeen athletes were 8 practicing sport and physical exercise at recreational level, 353 at departmental to regional 9 level, and 127 at national to international level. 10 procedure 11 nonprobability snowball sampling was used to recruit participants (kosinski, matz, 12 gosling, popov, & stillwell, 2015). a web link to access the online questionnaire was sent to 13 a first wave of participants. they were also asked to forward this link to their own network. 14 the completion of the questionnaire was individual and anonymous. participants signed an 15 informed consent electronically. data were collected in mid-march 2020 for one week, one 16 month after the implementation of confinement in france. nonprobability snowball sampling 17 in individual web-based sessions was selected in the present study because of social 18 distancing rules that have been put in place by the french authorities to control the spread of 19 covid-19. concerning physical exercise, the french authorities only allowed short trips linked 20 to individual physical exercise, within the limit of one hour per day and within a maximum 21 radius of one kilometer around home. collective physical exercise was strictly forbidden. the 22 study was approved by the national ethics committee for research in sports sciences 23 (cerstaps irb00012476-2020-13-04-57) and met the requirements of the declaration of 24 confinement which had not been experimentally manipulated but imposed by the authorities 1 because of the health situation. 2 self-approach and self-avoidance goals were assessed twice with the two 4 corresponding subscales of the 3 x 2 achievement goal questionnaire for sport (agq-s, 5 mascret et al., 2015) initially validated in french language. participants were first asked to 6 answer items on a likert scale from 1 (strongly disagree) to 7 (strongly agree) assessing 7 retrospectively their self-approach goals (e.g., "when i was exercising before confinement, my 8 goal was to have better results than i had in the past") and self-avoidance goals (e.g., "when 9 i was exercising before confinement, my goal was to avoid doing worse than i usually do") 10 when they had physical exercise prior to the start of confinement. we used a retrospective 11 design to assess self-based goals before confinement because (a) it was not possible to initiate 12 the study before the start of confinement, (b) we were interested in the overall self-based 13 goals adopted when participants had physical exercise before confinement, and (c) with ω ranging from .73 to .94. we expected self-approach goals to decrease and self-21 avoidance goals to increase between the measures before and during confinement due to the 22 covid-19 outbreak (hypothesis 1). 23 intention to exercise during confinement was assessed based on a french translation of 24 the measure adapted from chatzisarantis, biddle, and meek (1997). participants responded to 25 j o u r n a l p r e -p r o o f confinement due to covid-19 and achievement goals 5 the three items (e.g., "i plan to exercise at least three times a week during confinement") on a 1 7-point scale ranging from 1 (very unlikely) to 7 (very likely). internal consistency was high 2 (ω = .97). physical exercise is defined in the present study as a "planned, structured and 3 repetitive bodily movement, the objective of which is to improve or maintain physical fitness" 4 (caspersen, powell, & christenson, 1985, p. 126). we expected both self-approach and self-5 avoidance goals to be positive predictors of intention to exercise in the particular context of 6 confinement, whereas self-avoidance goals were not usual predictors of intention to exercise 7 in a more conventional context. 8 preliminary analyses were previously conducted. no missing data were found. two 10 participants were excluded because they were identified as outliers using mahalanobis 11 distance (p < .001) at the multivariate level. skewness and kurtosis estimates indicated that 12 the measures of self-approach and self-avoidance goals were normal in distribution. all 13 statistical analyses were conducted using jasp software (version 0.12.2). 14 a repeated measures anova with the factors goals (self-approach, self-avoidance) 15 and time (before confinement, during confinement) revealed a significant effect of time 16 (f(1, 1392) = 201.09, p < .001, η p ² = .126) and a significant goals x time interaction (f(1, 17 1392) = 399.32, p < .001, η p ² = .223). post hoc comparisons using the tukey hsd test 18 indicated that the mean score for self-approach goals during confinement (m = 3.69, sd = 19 1.90) was significantly lower than before confinement (m = 5.47, sd = 1.51, p < .001). 20 conversely, the mean score for self-avoidance goals during confinement (m = 4.72, sd = 21 1.69) was significantly higher than before confinement (m = 4.42, sd = 1.79, p < .001). hypothesis 1 was confirmed. ancillary analyses showed that before confinement self-23 approach scores were significantly higher than self-avoidance goals (p < .001). the pattern 24 was reversed during confinement (p < .001). while improving themselves was athletes' goal with the highest score before confinement, avoiding regression became their goal with the 1 highest score during confinement. figure 1 illustrates the previous results. after standardizing the relevant variables to reduce multicollinearity, we conducted 5 hierarchical regression analyses to examine how gender (women = 0, men = 1), age, sport 6 level (step 1), self-based goals (step 2), and the interactions between self-based goals and 7 gender, age, and sport level (step 3) predicted intention to exercise during confinement. 8 gender, age, and sport level were included in the hierarchical regression analyses to control 9 for these variables. the results showed that self-approach and self-avoidance goals were both 10 positive predictors of intention to exercise during confinement. hypothesis 2 was confirmed. 11 ancillary analyses finally showed that results did not change when the control variables were 12 removed. a significant interaction was also found between self-avoidance goals and sport 13 level and was then decomposed by simple slopes analyses (aiken & west, 1991) at ±1sd. 14 this interaction effect was not represented because simple slope analysis did not reveal 15 significant findings (p = .726 for low sport level and p = .457 for high sport level). table 1 16 shows the detailed results of the final regression analyses. 17 insert table 1 about here 18 19 discussion 20 the results of the present study indicated that the confinement situation and the 21 physical exercise restrictions due to the covid-19 outbreak influenced self-based goals of 22 regular athletes of different sport levels. self-approach goals decreased but kept their 23 predicting role on intention to exercise already found in the literature before confinement 24 (lochbaum et al., 2020). self-avoidance goals increased, became the goals with the highest 25 score, and appeared to be positive predictors of intention to exercise during confinement. 26 j o u r n a l p r e -p r o o f confinement due to covid-19 and achievement goals 7 these results reinforced the fact that achievement goals are context-specific. benita and 1 colleagues (2014, 2017) highlighted that adopting mastery-approach goals in a controlled 2 context (with constraints) promoted lower positive emotional experiences than in an 3 autonomous context (with choice and volition). the strong constraints associated with 4 physical exercise, implemented by the french authorities to limit the spread of covid-19, may 5 be experienced by regular athletes as a form of controlled context which have impacted both 6 their self-based goals and their predicting role on intention to exercise. moreover, self-7 avoidance goals combine positive (intrapersonal) and negative (avoidance) components and, 8 theoretically, positive or negative outcomes may be induced depending on the predominant 9 component (senko & freund, 2015) . in the context of physical exercise during confinement, 10 self-avoidance goals were more likely to be positive predictors of intention to exercise 11 because they were more functionally-congruent with the context (conroy, cassidy, & elliot, 12 2008), which was not the case before confinement. the present study conducted with athletes 13 in the particular context of confinement reinforces the general assumptions that "different 14 achievement goals may be better suited for different types of situations" (barron & 15 harackiewicz, 2001, p. 708), that mastery-avoidance goals -especially self-avoidance goals -16 are not always maladaptive (mascret, nicolleau, & ragot-court, 2020; senko & freund, 17 some limitations of the present study need to be acknowledged. first, the study used a 20 retrospective design and the particular context of confinement could have been influenced 21 athletes' answers when they were asked to remember and to rate their self-based goals before 22 confinement. secondly, the study did not investigate participants' types of sport. it would 23 have been interesting to examine for instance whether the pattern of results remained the same 24 between individual and team sports. 25 j o u r n a l p r e -p r o o f confinement due to covid-19 and achievement goals 8 while improving themselves was the goal with the highest score before confinement, 1 avoiding regression became the athletes' goal with the highest score during confinement and 2 predicted their intention to exercise during this period. this is of particular broad interest 3 because these results confirmed that human beings are capable of changing their goals in 4 order to adapt as well as possible to a particular situation, here a situation as exceptional as 5 confinement linked to a pandemic. .188 (.182***) self-approach goals 1 .51*** self-avoidance goals 1 .38*** step 3 .201 (.013) self-approach goals x gender .07 self-avoidance goals x gender -0.03 self-approach goals x age -0.01 self-avoidance goals x age -0.01 self-approach goals x sport level -0.19 self-avoidance goals x sport level -0.21* note. *p < .05, **p < .01, ***p < .001 a meta-analytic review of hierarchical model of approach and avoidance motivation in the 13 sport, physical activity, and physical education literature the 2× 2 achievement goals in sport and 16 physical activity contexts: a meta-analytic test of context, gender development and validation of a scale 1 assessing achievement goals in driving are mastery-avoidance achievement goals always 4 detrimental? an adult development perspective achievement goals and motivational responses in 7 tennis: does the context matter? a novel approach to assessing achievement goals in the context of 10 the 2 × 2 framework: identifying distinct profiles of individuals with different 11 dominant achievement goals achievement goals and self-regulation in the sport 14 context key: cord-332496-xxz6qd3i authors: jiménez, óliver; sánchez-sánchez, laura c.; garcía-montes, josé m. title: psychological impact of covid-19 confinement and its relationship with meditation date: 2020-09-11 journal: int j environ res public health doi: 10.3390/ijerph17186642 sha: doc_id: 332496 cord_uid: xxz6qd3i the objective of this study was to evaluate the psychological impact of confinement due to the covid-19 pandemic, considering any protective factors, such as the practice of meditation or self-compassion, and their relationship with different lifestyles and circumstances of adults residing in spain. a cross-sectional study was done using an anonymous online survey in which 412 participants filled out the depression, anxiety and stress scale-2; the impact of events scale; and the self-compassion scale-short form, reporting severe symptomatology of posttraumatic stress and mild anxiety and depression. quality of cohabitation and age were found to be key variables in the psychological impact of confinement. the impact of confinement was more negative for those who reported very poor cohabitation as opposed to very good (f (3, 405) = 30.75, p ≤ 0.001, d = 2.44, r = 0.054) or for those under 35 years of age compared to those over 46 (f (2, 409) = 5.14, p = 0.006, d = 0.36). practicing meditation was not revealed as a protective factor, but self-compassion was related to better cohabitation during confinement (f (3, 403) = 11.83, p ≤ 0.001, d = 1.05). these results could be relevant in designing psychological interventions to improve coping and mental health in other situations similar to confinement. in december 2019, an outbreak of pneumonia with an unknown etiology was announced in wuhan (china), soon becoming a global pandemic and surpassing the severe acute respiratory syndrome (sars) of 2003 [1] . the world health organization (who) identified this new pneumonia as a new coronavirus called sars-cov-2 or as it is commonly called, covid-19. since the first cases were recorded in december 2019, the number has increased exponentially throughout the world and a public health emergency of international interest was declared on 30 january 2020 [2] . by march 11th, covid-19 had already been declared a worldwide pandemic with 118,000 cases in 114 countries, although 90% of them were concentrated in china and the republic of korea [3] . at the time of writing, 28 june 2020, global coronavirus cases surpassed 10 million, with over half a million deaths. in europe, over 2.5 million people have been infected, with almost 200,000 deaths, and spain has had the third most cases in europe, with 248,770, and the sixth most deaths, with 28,343 [4] . this rapid expansion of the virus is partly due to its high transmissivity, which has an estimated basic reproduction number of 2.24 to 3.58, meaning that an individual who is a transmitter of the virus could infect from two to four others [5] , even though they do not show any symptomatology [6] , and its incubation period varies from two to 14 days, with an average of seven days [7] . the symptomatology of those infected is fever, dry cough, sore throat, difficulties breathing, fatigue, nausea, vomiting, and diarrhea. the most commonly reported comorbidities are hypertension, diabetes, headache, dizziness, fatigue, myalgia, hypo/anosmia, and gustatory dysfunction [8] . regarding psychiatric and neuropsychiatric presentations, it seems that in its acute stage, sars-cov-2 might cause delirium in a significant proportion of patients. it might also cause depression, anxiety, fatigue, posttraumatic stress disorder, and more rarely, in the long-term, neuropsychiatric syndromes [9] . covid-19 can infect people of all ages, but men over 70 with preexisting conditions, such as asthma, diabetes, or heart disease, are the most susceptible, reporting an >8% mortality rate [5] . women are less susceptible to infection and because of their distinctive immune system, severity and mortality are much lower in children than in adults [5] . in view of all of the above and especially because of the rapid expansion of the epidemic, many countries have decreed a state of emergency with mass quarantine of their citizens. in the particular case of spain, this state of emergency has imposed a closure of establishments, ceasing of all except essential activity, and home confinement of the population during a period of time depending mainly on the evolution of the number of people infected and the expansion of the virus. in this respect, recent studies [10, 11] have mentioned that understanding the effect this quarantine has on the population is of great importance, especially in countries as severely affected as spain. quarantine could be understood as an important source of stress as it is unpredictable and uncontrollable, which are core features of the psychobiological construct of stress [12] . a recent review [10] on the psychological impact of quarantining for sars, h1n1 flue, and other causes reported fear in over 20% of the population, 18% sadness and 10% blame, and a high prevalence of distress, stress, depression, or bad mood. some of the factors generating stress during the sars quarantine were duration and fear of infection. some studies showed a positive association between length of quarantine and increase in posttraumatic stress symptoms, avoidance behaviors, or anger [10] . in recent studies on the impact of covid-19, women have manifested a greater psychological impact and worse mental health [13] . young people and students are also more vulnerable because of schools and universities closing, as well as social isolation, altering the normal development of their education [14] . in such a situation, systematic psychological self-care should have a high priority in coping with the detrimental impacts of covid-19 and social distancing. thus, acknowledging one's own limitations with compassion as a part of the shared human experience could have a positive impact on mental health. in this respect, possible protective factors could be mindfulness or self-compassion, since, as mentioned in a recent review [15] , it seems that mindfulness-based treatments are effective in reducing posttraumatic stress disorder (ptsd) symptoms and the mindfulness-based stress reduction program was the one that provided the most evidence [16] . in this vein, another review [17] emphasized the promising results associating an increase in self-compassion with reduction in ptsd symptoms, reducing the impact of exposure to trauma. therefore, and since to date there are few studies reporting on the emotional impact the pandemic is having on the psychological health of those confined, the objective of this study was to explore the impact of confinement due to covid-19 on the mental and emotional health of adult spanish-speaking residents of spain. in particular, we intended to inquire into the possible impact of confinement on anxiety, depression, and posttraumatic stress and whether practice of some type of meditation or self-compassion could be a protective factor against this impact. then, any between-group differences in these variables would be analyzed by sample sociodemographic variables (age, cohabitation, etc.) and finally, the relationships between the abovementioned variables (anxiety, depression, stress, self-compassion) and the sociodemographic variables selected (e.g., age or treatment of those confined) would be explored. a total of 412 adults from 63 spanish provinces, with a mean age of 40.48 (sd = 10.79) participated in the survey out of a total of 420 (finalization rate: 98.09%). most of the participants were spanish (91%), women (84.5%), aged 18 to 73, with no changes in their employment because of covid-19 (73.8%), a university education (42%), and did not practice any type of meditation (69.9%). the rest of the sociodemographic variables recorded are presented in table 1 . data collected for the study were sociodemographic (gender, age, nationality, marital status, occupation, employment, education); health (whether under treatment or not and if so, what); quality of cohabitation during the pandemic; cohabitation with a case of covid-19; whether religious or not and if so, practicing or not; and whether they practiced mediation and if so, what type. mental health was evaluated using the following scales: depression, anxiety and stress scale-21 (dass-21). the dass-21 consists of 21 items evaluating the frequency and severity of emotional symptoms experienced during the previous week, using a self-report scale with four choices from 0 (never) to 3 (almost always). it is made up of three subscales, depression, anxiety, and stress, with seven items each. a high score on each subscale means stronger symptomatology ( [18, 19] spanish adaptation). internal consistency of the spanish adaptation has an α = 0.93 for the depression scale, α = 0.86 for anxiety, α = 0.91 for stress, and α = 0.96 for the total scale [19] . impact of events scale (ies). the ies consists of 15 items evaluating subjective stress from stressful and or traumatic experiences in the previous week, with two subscales, intrusion and avoidance, with seven and eight items, respectively ( [20, 21] spanish adaptation). it is a four-choice self-report scale varying from 0 (never) to 4 (often). based on the sum of all the items, the cutoff points are 8.6 to 19 for mild symptoms and 19 or over for severe symptoms. the internal consistency of the spanish adaptation has an α =.86 for the total scale, α = 0.76 for intrusion and α = 0.82 for avoidance [21] . self-compassion scale-short form (scs-sf). the short form of the scale is made up of 12 items that evaluate self-compassion ( [22, 23] spanish adaptation). it consists of three main subscales (mindfulness, self-kindness, and common humanity) and their opposites (over-identification, self-judgment, and isolation). the scale has five answer choices from 1 (almost never) to 5 (almost always). a higher score is interpreted as more self-compassion. the internal consistency of the spanish adaptation is α = 0.71 for self-judgment, α = 0.75 for common humanity, α = 0.77 for isolation, α = 0.74 for mindfulness, α = 0.76 for over-identification, α = 0.73 for self-kindness, and α = 0.85 for the total scale [23] . a cross-sectional study was conducted from 4 april 2020 to 1 may 2020. the sample was recruited by non-probabilistic snowball sampling, since it was an exploratory study in which rapid access to data was needed. first, contacts of the research team were invited to participate and then, these contacts were asked to forward the invitation to their contact networks. an online survey form was prepared using google forms, which included information on the study; telling the participants that they would not receive any compensation for taking part in it; a series of sociodemographic and additional variables of interest; and the dass-21, ies, and scs scales. the study protocol was approved by the university of almería bioethics committee (no. ualbio2020/032) and the participants signed their consent after being informed of the implications of their participation and the confidentiality of the data provided, according to the helsinki declaration and the organic law on data protection 15/1999 of december 13th. all the analyses were performed with spss version 26.0 (ibm corp., armonk, ny, usa) and the descriptive results of the quantitative variables were reported with mean and standard deviation. an anova was done to evaluate the between-group differences in the sociodemographic variables and then, a student's t-test was applied for comparisons between each pair of groups. further, the effect size was calculated for those that were statistically significant. finally, the bivariate correlation was calculated to evaluate the relationship of the different sociodemographic ordinal variables and subscales. in all the analyses, p < 0.05 was considered statistically significant. the general mean on the dass-21 scale for participant stress was 6.67 (sd = 5.25), 3.88 (sd = 4.51) for anxiety and 4.51 (sd = 4.54) for depression, which reflects mild depression and anxiety, and the stress score was not symptomatic. on the ies scale, the mean for intrusion was 12.61 (s = 7.39), 13 .66 (sd = 7.62) for avoidance, and on the total scale, it was 26.22 (sd = 13.78), which shows severe symptomatology. finally, on the scs scale, mean self-kindness was 6.46 (s = 1.67) and for common humanity, it was 6.44 (sd = 1.60) and in mindfulness, it was 6.69 (sd = 1.69). an anova was done with the most significant variables to test for differences between the sociodemographic variables and psychological scales. this section only shows the data for those sociodemographic variables that were statistically significant. to be able to compare the groups by age, a new variable was created a posteriori by grouping participants by age into three groups of equivalent size by the quartiles found from the cutoff points. this new variable, "age group", was divided into young adults (18 to 35), adults (36 to 45), and middle aged (over 46). in addition, and since one of the objectives of this study was to test the importance of meditation on the psychological impact of confinement, this variable was also included for testing. after the anova and meeting the assumptions of normality and homogeneity of variance, statistically significant differences were found between psychological variables and sociodemographic variables. in stress, significant differences were found between age groups [f (2, 409) = 5.14, p =0 the results show that the total ies scores were lower in the groups with the best cohabitation, with a large effect size, except between very good and good, which was small, and between good and poor, which was moderate. differences were found with regard to occupation [f from the comparison between groups, it may be seen that the scores on common humanity were higher in those groups where cohabitation was better, with a large effect size. finally, statistically significant between-group differences were also found between groups by type of meditation [f (4, 396) = 6.10, p ≤ 0.001], especially between none and mindfulness (m = 6.23, sd = 1.54 vs. m = 7.02, sd = 1.64, d = 0.50, r = 0.001) and between none and transcendental (m = 6.23, sd = 1.54 vs. m = 8.00, sd = 1.58, d = 1.14, r = 0.004). in both cases, the participants who showed more common humanity were those who practiced some type of meditation compared to those who did not, with a moderate effect size between those who did not and those who did practice mindfulness and a large effect size between those who did not practice and those who practiced transcendental meditation. concerning the last subscale, mindfulness, statistically significant differences were observed between age groups [f ( in general, in those groups that practiced meditation, the score on the mindfulness scale was higher than in those who did not practice any, with a large effect size, except between none and mindfulness, which was small. lastly, by type of occupation, statistically significant between-group differences [f (6, 398) = 2.96, p < 0.05] were also found between unemployed and housewife/husband the rest of the sociodemographic variables with their mean and standard deviation are shown in table 2 . after the correlation analysis, older age was observed to be related to higher frequency in practicing meditation, better cohabitation, more common humanity, and more mindfulness. on the contrary, less stress, anxiety, and depression were related with older age. higher education was significantly related to more frequent practice of meditation and an increase in the variables in the scs scale. on the contrary, greater anxiety, intrusion, and avoidance were related to a lower education. more frequent meditation practice was significantly related to less depression and an increase in scs scale variables. better cohabitation quality was significantly related to higher scores on scs variables and a lower score on the rest of the scales. finally, as expected, the psychological scales were significantly correlated with each other (see table 3 ). after analyzing the survey results with regard to the objectives originally set, the participants showed mild depression and anxiety, not reporting symptoms of stress. however, they did report severe symptomatology on the ies scale as in previous studies, which related high scores in posttraumatic stress symptoms or avoidance behaviors after 10 days of quarantine [8] . this difference may be, in part, because the ies scale evaluates the psychological impact of an event after the fact and the participants could have understood that the event referred to covid-19, but not on the dass-21 scale. another of the objectives of the study proposed self-compassion and mindfulness as protective factors against the impact of confinement. it is worth mentioning that the participant scores on the various self-compassion scale subscales (mindfulness, self-kindness, and common humanity) were negatively related in both the ies and the dass-21, suggesting that self-compassion might be an important protective factor, fostering emotional resilience [24] . the results show that higher scores of self-kindness, common humanity, and mindfulness were related to not being under treatment and in turn, higher scores of self-kindness and common humanity were related to higher cohabitation quality. there was no significant relationship of mindfulness practice with lower scores on the ies or dass-21 scales, but there was an increase in the self-compassion scale, as was to be expected, given the relationship of mindfulness with self-compassion [25] . the sociodemographic variables that had the strongest relationship with psychological impact were being under treatment or not, age, and quality of cohabitation during the quarantine, indicating that not being under any treatment implied lower scores of intrusion and avoidance. being young was related to higher scores of stress and depression, in agreement with recent studies on the psychological impact, relating age and being a student with higher vulnerability and psychological impact from confinement [14, 26] . furthermore, an improvement in quality of cohabitation was related to a lower total ies score. on the contrary, worse cohabitation is related to greater intrusion and avoidance. these results would suggest that young people under some type of treatment and who report that the quality of their cohabitation is not good, would experience a negative psychological impact of confinement. specifically, young people show more posttraumatic stress symptomatology, so it would be of interest for authorities to develop psychological interventions, providing a support network during quarantine as previous studies have related an increase in ptss after similar events, such as middle east respiratory syndrome [27] . it was also observed that cohabitation with a person who was covid-19 positive implied more intrusive thoughts and avoidance, as well as a higher score on the total ies, which would be related to experiencing more fear of becoming infected with the virus and in turn, infecting others [10, 28, 29] . being retired was also related to more intrusion and a higher total score on the ies scale and on the contrary, being a student was related to less intrusion and a lower score on the total ies scale. this study has some limitations, especially due to the limited resources available and the urgency in its implementation during the state of emergency. we cannot establish any causal relationships between the variables studied. the sample was mostly comprised of women and only an adult population, so it is not a true representation of the entire population. future studies should have a larger and more homogeneous sample and use a more complex sampling strategy or perform a prospective study that would enable a more specific result to support the need for health initiatives focused on improving the mental health of the participants, promoting attitudes or behaviors for coping with confinement. in spite of these limitations, the results of this study provide important information on the psychological and social impact of the first three weeks of a covid-19 quarantine period, including that self-compassion might be an important protective factor, and may be used as a reference in future epidemics or outbreaks of the virus that provoke similar short or long-term situations to generate hypotheses for improvement of prevention and intervention. the results could also provide a baseline for evaluating the psychological and social consequences during the rest of the covid-19 epidemic, which was still underway at the time of writing. during this first stage of confinement due to the covid-19 outbreak, the participants reported mild anxiety and depression symptomatology, as well as severe posttraumatic stress symptomatology. the quality of cohabitation was shown to be a key variable in the psychological impact of the participants, since its poorer quality was related to higher scores of intrusion and avoidance, which were lower the better the quality of cohabitation was. being young and being under treatment were also related to a greater psychological impact. finally, self-compassion was related to better cohabitation during confinement. the findings shown in this study could be used for psychological interventions to improve mental health and coping with confinement during the covid-19 epidemic. sars control and psychological effects of quarantine china coronavirus: who declares international emergency as death toll exceeds 200 considerations for quarantine of individuals in the context of containment for coronavirus disease (covid-19) who. coronavirus 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items) and short (12 items) forms of the self-compassion scale (scs). health qual self-compassion: an alternative conceptualization of a healthy attitude toward oneself immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china mindfulness estado, habilidades mindfulness y auto-compasión en el aprendizaje de mindfulness: un estudio piloto impacto psicológico de la pandemia de covid-19: efectos negativos y positivos en población española asociados al periodo de confinamiento nacional mental health status of people isolated due to middle east respiratory syndrome the emotional impact of covid-19: from medical staff to common people this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the authors would like to thank all the participants and the university of almeria's third generation behaviour therapy training program for their suggestions about the content of this article. key: cord-341724-yxkobcw9 authors: di fabio, annamaria; saklofske, donald h. title: the relationship of compassion and self-compassion with personality and emotional intelligence in organizations date: 2020-05-11 journal: pers individ dif doi: 10.1016/j.paid.2020.110109 sha: doc_id: 341724 cord_uid: yxkobcw9 the two studies presented in this article examine the relationships of personality traits and trait emotional intelligence (ei) with compassion and self-compassion in samples of italian workers. study 1 explored the relationship between trait ei and both compassion and self-compassion, controlling for the effects of personality traits in 219 workers of private italian organizations. hierarchical regression analyses revealed that trait ei explained variance beyond that accounted for by personality traits in relation to both compassion and self-compassion. study 2 analyzed the contribution of trait ei in mediating the relationship between personality traits and both compassion and self-compassion of 231 workers from public italian organizations with results supporting the mediating role of trait ei. regarding the association between compassion and well-being, a brief compassion training with a sample of healthy adults resulted in participants' experiencing higher positive affect compared to a control group (klimecki, leiberg, lamm, & singer, 2012) . people who receive compassion appear to recuperate faster from physically from illness (brody 1992) and psychologically from grief (bento 1994 , doka 1989 . compassion satisfaction felt by nurses was positively associated with well-being (kim & yeom, 2018; kim et al., 2017) and inversely associated with burnout (kim et al., 2017) . extending compassion to the self, self-compassion refers to a regulation strategy in which feelings of worry or stress are not avoided but instead being open and sensitive to one's own suffering, experiencing feelings of care and kindness to oneself, taking an attitude of understanding and not judging one's own inadequacies and failures, and recognizing that one's own experience is part of the common human experience (neff, 2003) . self-compassion is also associated with feelings of compassion and concern for others so that being compassionate towards oneself does not mean being focused only on one's own personal needs (neff, 2003) . in particular, self-compassion acknowledges that suffering, failure, and inadequacy are part of the human condition and all people, including themselves, are worthy of compassion (neff, 2003) . research on self-compassion has shown increased performance and benefits in overcoming mental barriers, aversive thoughts, fear of failure, and negative emotions (neff & knox, 2017) . other studies have reported positive associations of self-compassion to goal mastery (neff, hsieh, & j o u r n a l p r e -p r o o f lim, & consedine, 2018) . self-compassion is considered a resilience factor that promotes wellbeing at work (dev et al., 2018) while showing inverse associations with emotional exhaustion and burnout at the workplace (alkema, linton, & davies, 2008; dev et al., 2018) . compassion and self-compassion have been linked with personality traits grounded in models including the big 5 and the hexaco (arslan, 2016; goetz, 2008; graziano & eisenberg, 1997; neff, 2003; neff, rude, & kirkpatrick, 2007; oral & arslan, 2017; thurackal, corveleyn & dezutter, 2016) . with personality traits being such key predictors of human behaviour, it is not surprising to find that compassion shows a positive relationship with agreeableness (goetz, 2008; graziano & eisenberg, 1997) while self-compassion appears to be inversely related with neuroticism (arslan, 2016; neff, 2003; neff, rude, & kirkpatrick, 2007; oral & arslan, 2017; thurackal, corveleyn & dezutter, 2016) . strength-based preventive studies (di fabio & saklofske, 2014a , 2014b have also identified emotional intelligence as a promising primary prevention resource (di fabio & kenny, 2011 , 2015 , 2016b since it is amenable to training, in contrast with personality traits which are somewhat more stable (costa & mccrae, 1992) . the two major descriptions of emotional intelligence (stough, saklofske, & parker, 2009 ) include ability-based models (mayer & salovey, j o u r n a l p r e -p r o o f sheena, & sladea, 2018 , vesely, saklofske, & nordstokke, 2014 vesely-maillefer & saklofske, 2018) . nightingale et al. (2018) reviewed 22 papers that explored the relationship between ei and caring behaviour in health care professionals but only one study specifically centered on relationships between ei and compassion. dafeeah, eltohami, and ghuloum (2015) showed that higher ei results in higher nurse/physician self-reported emotional care/compassion compassionate attitudes toward patients with hiv. in a related vein, zeidner et al. (2013) , reported that compassion fatigue defined as the negative consequence of working with patients in combination with a deep, personal, empathetic orientation (abendroth, 2011) was inversely associated with both trait emotional intelligence and ability-based emotion management in health-care professionals. a more recent study of nurses (beauvais, andreychik, & henkel, 2017) showed that compassion fatigue was inversely associated with ability based emotional intelligence whereas compassion satisfaction showed a positive relationship. regarding the self-compassion and ei, neff (2003) highlighted that self-compassion was related the ability to monitor one's own emotions and the ability to skillfully use this information to guide this study examined the relationships of both compassion and self-compassion with trait ei factors, controlling for the effects of personality traits (big five model) with a sample of workers in private italian organizations. the following research questions were examined: trait ei factors are positively associated with compassion and self-compassion, and ei will add additional variance to that accounted for by the big five personality traits in relation to compassion and self-compassion. two hundred and nineteen workers from private italian organizations participated in the study (54% men, 46% women). the participants ranged in age from 25 to 64 years (m = 40.83, sd = 9.26). the participation rate was 91%. not at all true of me to 7 = completely true of me). the scale provides a total score and scores for five dimensions that include recognizing suffering, understanding the universality of suffering, emotional connection, tolerating uncomfortable feelings, and acting to help/alleviate suffering. the total score (alpha reliability coefficient = .83) was used in the present study. self-compassion scale (scs). the self-compassion scale (neff, 2003) , translated into italian by di fabio (2017b) includes 26 items answered on a 5-point likert scale (1= almost never to 5 = almost always). the six compassions dimensions assessed by the scs include: self-kindness, selfjudgement, common humanity, isolation, mindfulness, and over-identification. the total scs scale with a cronbach alpha coefficient of .82 was used in the present study. the questionnaires were administered to small groups by trained psychologists. the order of administration was counterbalanced to control the possible effects of presentation of the instruments. the instruments were administered according to the requirements of privacy and informed consent of italian law. descriptive statistics, pearson's r correlations and hierarchical regressions were calculated. means, standard deviations, and correlations between the bfq, teique-sf, cs, and scs are shown in table 1 . table 1 table 2 shows the results of hierarchical regression model with compassion as the dependent variable and the bfq entered at the first step followed by the four dimensions of trait ei at the second step. j o u r n a l p r e -p r o o f please insert table 2 with regard to compassion, personality traits accounted for 36% of the variance at step one and the four dimensions of trait ei added a further 20%, accounting overall for 56% of the variance. table 3 shows the results of hierarchical regression model with self-compassion as dependent variable and with bfq at the first step and the four dimensions of trait ei at the second step. personality traits accounted for 52% of the variance in self-compassion at step one and the four dimensions of trait ei added only 6%, accounting overall for 58% of the variance. table 3 5 the present study examined the relationship between both compassion and self-compassion, personality traits (big five model) and trait ei dimensions including an analysis of the relationships of the combined effects of personality and trait ei. trait ei was significantly associated with compassion and added substantial incremental variance beyond personality. in particular, emotionality showed the strongest relationship with compassion indicating that individuals who are able to recognize and express their emotions (petrides, 2009; petrides & furnham, 2001 ) also perceive themselves as more compassionate (gu et al., 2017) . emotionality, together with the trait ei factors of self-control and well-being, appear to be a key while ei did not account for a large amount of additional variance beyond personality traits in relation to self-compassion, self-control and well-being showed the strongest relationships. this suggests that managing one's own emotions (self-control) and having positive personal emotional strengths (well-being) (petrides, 2009; petrides & furnham, 2001 ) may contribute to increased openness and sensitivity to one's own suffering, experiencing feelings of care and kindness to j o u r n a l p r e -p r o o f oneself, taking an attitude of understanding and not judging one's own inadequacies and failures, and recognizing that one's own experience is part of the common human experience (di fabio, 2017b; neff, 2003) . following from the results obtained above, study 2 further examined the relationship between personality, ei and compassion and self-compassion but focused on whether trait ei mediates these relationships. in relation to compassion, we hypothesized that: the trait ei dimensions of emotionality, self control and well-being will mediate the relationship between agreeableness and compassion, and that emotional stability will be positively correlated with both trait ei dimensions and self-compassion. for self-compassion, we predicted positive correlations with trait ei dimensions (self-control and well-being) and that trait ei dimensions (self-control and well-being) will mediate the relationship between emotional stability and self-compassion. we considered ei as a mediator in the relationships between personality traits and compassion and self-compassion because ei is amenable to training (di fabio & kenny, 2011) in contrast to personality traits that are considered to be relatively stable (costa & mccrae, 1992) . as well, ei mediated compassion satisfaction (valavanis, 2019) and showed consistent positive associations with criteria for wellbeing (austin, saklofske, & egan, 2005). means, standard deviations, and correlations for the bfq, teique-sf, cs, and scs are shown in table 4 . please insert table 4 the five personality factors were positively and significantly correlated with all teique factors with one exception and also showed significant correlations with compassion and with one exception, self-compassion. for the teique, emotionality (.64), well-being (.57), and self-control (.48) showed significant correlations with compassion. subsequently we performed three mediation analyses, using the personality trait of agreeableness as the independent variable, given that it had the highest correlation with compassion, and the three teique dimensions of emotionality, wellbeing and self-control as mediators, again because of their higher correlations with compassion. agreeableness was positively and directly associated with compassion and also indirectly associated with compassion through emotionality. as can be seen in figure 1 , participants who had higher agreeableness perceived themselves to have more emotionality (a = .37) and in turn, perceived also themselves to have more compassion (b = .96). a bias-corrected bootstraps confidence interval for the indirect effect (ab = .36) based on 5000 bootstrap samples was entirely j o u r n a l p r e -p r o o f compassion. this was followed by two mediation analyses, using the personality traits of emotional stability as the independent variables and the two teique dimensions of self-control and wellbeing as mediators. emotional stability was positively and directly associated with self-compassion and also indirectly through self-control. figure 4 shows that participants with higher emotional stability view themselves as having more self-control (a = .33) and in turn, as feeling more self-compassion (b = .88). a bias-corrected bootstraps confidence interval for the indirect effect (ab = .29) based on 5000 bootstrap samples was entirely above zero (.18 to .42). the effect of emotional stability on selfcompassion was reduced after controlling self-control, although remaining significant (path c' in figure 1 ; p < .001): these results therefore indicated a partial mediation model, with r 2 = .31, p < .001). please insert figure 4 the second mediation model further showed that emotional stability was directly and positively associated to self-compassion as well as indirectly through well-being. figure 5 shows participants who had higher emotional stability rated themselves as having greater sense of more well-being (a = .19) who then further reported greater feelings of self-compassion (b = .74). a bias-corrected bootstraps confidence interval for the indirect effect (ab = .14) based on 5000 bootstrap samples was entirely above zero (.08 to .21). the effect of emotional stability on self-compassion was reduced after controlling well-being, although remaining significant (path c' in figure 1 ; p < .001): these results therefore indicated a partial mediation model, with r 2 = .14, p < .001). please insert figure 5 the link between agreeableness and compassion is in line with previous research (goetz, 2008; graziano & eisenberg, 1997) . the trait ei facets of emotionality, self-control, and well-being dimensions were positively correlated with compassion confirming the results obtained in study 1. furthermore, the relationship between agreeableness and compassion was mediated by emotionality; well-being and self-control results supported a partial mediation model see also di fabio, 2019; gu et al., 2017) . the interaction between agreeableness, emotionality and compassion is in line with recognizing emotions in self and others, being able to express emotions to others, and manifesting empathy and sharing fulfilling personal relationships (petrides & furnham, 2001; petrides, 2009 ). the findings of this study also supported previous research suggesting that emotional stability is associated with self-compassion (arslan, 2016; neff, 2003; neff et al., 2007; oral & arslan, 2017; thurackal et al., 2016 ) (h4). the trait ei facets of self-control and well-being were positively associated with self-compassion, confirming the results obtained in study 1 and previous research (heffernan et al., 2010; neff, 2003; senyuva et al., 2014) (h5) . furthermore, the relationship between emotional stability and self compassion was mediated above all by self-control and the well-being ei facets, although the results indicated a partial mediation model. these findings highlight the promising contribution of trait ei dimensions, especially self-control, as a mediator between emotional stability and self-compassion (di fabio, 2017b; neff, 2003) . the two studies presented in this article have added to the reported relationships between personality traits, trait emotional intelligence (ei) and both compassion and self-compassion in two samples of italian workers. study 1 examined the relationships of both compassion and self-journal pre-proof j o u r n a l p r e -p r o o f compassion with trait ei, controlling for the effects of the big five personality traits. hierarchical regression analyses showed that trait ei (in particular, the emotionality dimension) accounted for variance in compassion beyond personality. furthermore, trait ei and especially self-control explained a percentage of variance beyond that accounted for by personality traits in relation to selfcompassion. study 2 further verified that specific trait ei dimensions mediated the relationships between big five personality traits and both compassion and self-compassion. this study showed the promising contributions of the teique dimension of emotionality in mediating the relationship between agreeableness and compassion, and of the teique dimension of self-control in mediating the relationship between emotional stability and self-compassion. taken together these findings show important contributions between the major individual differences constructs of ei and personality in relation both compassion and self-compassion. such findings have particular relevance for building human capacity that includes desirable qualities such as compassion, which, in turn, has implications for our interactions with others as well as self-care. ei has been shown to be dynamic in the sense that it can be increased or enhanced (vesely-maillefer & saklofske, 2018) . in combination with personality factors such as agreeableness, ei factors including emotionality may be key in the development and manifestation of compassion. the ever increasing research findings and applications gleaned from positive psychology (seligman & csikszentmihalyi, 2000; seligman, steen, park, & peterson, 2005) have clearly shown the benefits to psychological health and well-being of individuals, organizations, and society. as shown in the literature review earlier in this paper, compassion and self-compassion must certainly be regarded as one of the central tenets of positive psychology. notwithstanding these promising results, it is necessary to note some limitations of the two studies reported here. the participants were italian workers from the tuscany region and thus future research should extend the study to workers from different geographical areas of italy and other countries and also to include different target groups (e.g., unemployed, general population). future studies should also consider demographics and background variables, for example gender, age and j o u r n a l p r e -p r o o f seniority at work as potential intervening factors. future research could also explore relationships with other models of trait emotional intelligence (e.g., bar on, 1997) and ability-emotional intelligence l (mayer & salovey, 1997) as well also different personality models (e.g., hexaco; ashton & lee, 2009). in conclusion, these two studies add support to the role of trait emotional intelligence as an important and even primary factor in developing and promoting both compassion and selfcompassion. emotional intelligence education and training may be regarded as a key component in strength-based programs (di fabio & saklofske, 2014a , 2014b intended to support healthy organizations and workers (di fabio, 2017a; peirã³ & rodrã­guez, 2008; tetrick & peirã³, 2012) . and compassion would seem to be a most powerful human emotion and expression that has far reaching implications for the self, others and the world we live in. j o u r n a l p r e -p r o o f table 1 note. n = 219. ** p < .01. * p < .05. step 2 teique well-being .12* compassion for others and self-compassion: levels, correlates, and relationship with psychological well-being emotional intelligence and its role in recruitment of nursing students exploring compassion: a meta-analysis of the association between self-compassion and psychopathology emergent organizational capacity for compassion is self-compassion selfish? the development of self-compassion, empathy, and prosocial behavior in adolescence what is emotional intelligence? the handbook of emotional j o u r n a l p r e -p r o o f work design-performance relationships work stress, leadership and organizational health job insecurity in the younger spanish workforce: causes and consequences psychometric properties of the trait ei questionnaire trait ei: psychometric investigation with reference to established trait taxonomies bringing self-kindness into the workplace: exploring the mediating role of selfcompassion in the associations between attachment and organizational outcomes using experience sampling to examine links between compassion, eudaimonia, and pro-social behavior emotional attention, clarity, and repair: exploring emotional intelligence using the trait meta-mood scale emotion, disclosure, & health development and validation of a measure of emotional intelligence positive psychology: an introduction positive psychology progress: empirical validation of interventions relationship between self-compassion and emotional intelligence in nursing students social connection and compassion: important predictors of health and well-being measuring compassion satisfaction as well as fatigue: developmental history of the compassion satisfaction and fatigue test the concise proqol manual assessing ei: theory, research, and applications occupational safety and health personality and self-compassion: exploring their relationship in an indian context the relationships between nurses' emotional intelligence, attachment style, burnout, compassion and stigma. doctoral dissertation ei training and pre-service teacher wellbeing emotional intelligence and the next generation of teachers awakening compassion at work: the quiet power that elevates people and organizations linking self-compassion and prosocial behavior in adolescents: the mediating roles of relatedness and trust personal factors related to compassion fatigue in health professionals the relationship between self-compassion and well-being: a meta-analysis key: cord-277086-j7hih6o9 authors: atchison, christina j; bowman, leigh; vrinten, charlotte; redd, rozlyn; pristera, philippa; eaton, jeffrey w; ward, helen title: perceptions and behavioural responses of the general public during the covid-19 pandemic: a cross-sectional survey of uk adults date: 2020-04-03 journal: nan doi: 10.1101/2020.04.01.20050039 sha: doc_id: 277086 cord_uid: j7hih6o9 objective: to examine risk perceptions and behavioural responses of the uk adult population during the early phase of the covid-19 epidemic in the uk. design: a cross-sectional survey setting: conducted with a nationally representative sample of uk adults within 48 hours of the uk government advising the public to stop non-essential contact with others and all unnecessary travel. participants: 2,108 adults living in the uk aged 18 years and over. data were collected between march 17 and 18 2020. main outcome measures: descriptive statistics for all survey questions, including the number of respondents and the weighted percentages. logistic regression was used to identify sociodemographic variation in: (1) adoption of social-distancing measures, (2) ability to work from home, and (3) willingness and (4) ability to self-isolate. results overall, 1,992 (94.2%) respondents reported taking at least one preventive measure: 85.8% washed their hands with soap more frequently; 56.5% avoided crowded areas and 54.5% avoided social events. adoption of social-distancing measures was higher in those aged over 70 compared to younger adults aged 18 to 34 years (aor:1.9; 95% ci:1.1 to 3.4). those with the lowest household income were six times less likely to be able to work from home (aor:0.16; 95% ci:0.09 to 0.26) and three times less likely to be able to self-isolate (aor:0.31; 95% ci:0.16 to 0.58). ability to self-isolate was also lower in black and minority ethnic groups (aor:0.47; 95% ci:0.27 to 0.82). willingness to self-isolate was high across all respondents. conclusions the ability to adopt and comply with certain npis is lower in the most economically disadvantaged in society. governments must implement appropriate social and economic policies to mitigate this. by incorporating these differences in npis among socio-economic subpopulations into mathematical models of covid-19 transmission dynamics, our modelling of epidemic outcomes and response to covid-19 can be improved. on 31 december 2019, chinese authorities notified the world health organisation (who) of an outbreak of pneumonia in wuhan city, which was later classified as a new disease: (1). following identification of cases in countries outside china, on 30 january 2020, who declared the outbreak of covid-19 a "public health emergency of international concern" (1). in the uk, the first cases of covid-19 were diagnosed at the end of january 2020, and community transmission was reported a few weeks later (2, 3) . government measures to control the epidemic were first announced on 22 january 2020 and included travel advice, information for those returning from affected countries, testing of suspected cases, isolation and contact tracing. this was followed in early february by a public health information campaign advising people to adopt hygiene measures to protect themselves and others, including more frequent handwashing with soap and water, using hand sanitiser if soap and water are not available, and covering mouth and nose with a tissue or sleeve when coughing or sneezing (4) . then, on 3 march 2020, the uk government published its action plan setting out the uk-wide response to the novel coronavirus. the uk government's response outlined measures in four key areas: containing the outbreak, delaying its spread, mitigating the impact and research to improve diagnostics and treatment (5) . on march 16 2020, five days after the who declared the outbreak of covid-19 a pandemic, the uk prime minister announced a shift to the delay phase of the uk response with measures aimed at suppressing the spread of the infection in the population through nonpharmaceutical interventions (npis), including social distancing of the whole population, isolation of cases for 7 days and quarantine of their household members for 14 days (6) . the public was advised to stop non-essential contact with others and all unnecessary travel: including working from home where possible and avoiding pubs, theatres, restaurants and other social venues (6) . this shift in response was prompted by a mathematical modelling study which showed that a combination of social distancing of the entire population, home isolation of cases and household quarantine of their family members (and possible school and university closure) was required to suppress transmission to a level that would enable the nhs to cope with the surge in cases requiring hospital admission and ventilation (7) . the effect of npis to reduce transmission rates is dependent on compliance with public health advice on social distancing. in the initial stages of the uk epidemic, this advice was voluntary, and not enforced by the government. this was criticised due to concern that likelihood of being infected with covid-19 under the uk government's current preventive measures. severity was measured by asking respondents about perceived seriousness of symptoms if they were infected with covid-19. preventive behaviours included information on perceived effectiveness and actual adoption of preventive behaviours (to protect oneself and others), to prevent both contracting covid-19 and onward transmission, and were collected under three categories: (1) hygiene practices (wearing a face mask, washing hands more frequently with soap and water, using hand sanitiser more regularly, disinfecting the home, covering nose and mouth when sneezing or coughing) (2) travel avoidance (travel to affected countries and travel to areas inside and outside the uk, regardless of whether they were affected) (3) social distancing (avoiding public transport, social events, going out in general, going to hospital or other healthcare settings, crowded places, and contact with people who have a fever or respiratory symptoms). willingness and ability to self-isolate if asked by a healthcare professional were measured using two questions developed for this survey. at the time the survey was conducted, public health england's operational definition of 'self-isolation' was "if you have symptoms of coronavirus infection , however mild, do not leave your home (even to buy food or essentials) or have any visitors for 7 days from when your symptoms started. this includes not going to work, school or other public places, and avoiding public transport or taxis. selfisolation is the same as voluntary quarantine."(12) we worked with yougov to optimise question clarity and ease of understanding for the uk population. the survey instrument is freely available to download from the school of public health, imperial college london covid-19 resources webpage: https://www.imperial.ac.uk/mrcglobal-infectious-disease-analysis/covid-19/covid-19-resources/ data were collected between 1630 gmt on 17 march 2020 and 1030 gmt on 18 march 2020. participants identified for the sample were sent an email with a survey link. yougov returned the anonymised data set to the imperial college london research team for analysis. analyses were conducted in stata 15 and spss version 25. descriptive statistics for all variables present the number of respondents and the weighted percentages. logistic regression was used to identify sociodemographic variation in: (1) adoption of socialdistancing measures, (2) ability to work from home, and (3) willingness and (4) ability to selfisolate. adoption of social distancing measures was proxied by respondents reporting to have avoided crowded places and social events to protect themselves or others from covidvariables that appeared to be associated (p<0.20) in the unadjusted analyses were considered in the adjusted analyses. adjusted odds ratios (aor) and 95% confidence intervals (ci) were estimated. associations with a p-value <0.05 in the adjusted analyses were considered to be statistically significant. we tested for collinearity between education level, employment status, household income, savings and household tenure. for these categorical variables, collinearity was measured by examining bivariate relationships using pearson's chi-squared tests. where collinearity was detected we ran separate adjusted regression analyses for those variables, using only other explanatory variables in those models that were not strongly correlated. we distributed an online feedback form to communities across the uk using local networks of public partners and contacts, twitter and via voice-global.org, an online platform for public involvement in research established by newcastle university. we received 420 responses, including 328 from members of the public. the experiences and feedback shared guided our study design and scope, including the phrasing of the survey tool's closed-ended questions and the refinement of pre-populated answer choices. study results will be shared with the public both by posting on the voice-global.org news page, on the research team's website and through direct mail with those who consented to be contacted about our research and involvement activity. the overall sample was designed to be representative of the uk adult population and is described in table 1 . in summary, of the 2,108 respondents, 11.1% were 18 to 24 years old, and 13.5% were 70 years or older. the majority of respondents were white (93.9%). in total, 43.4% were in full-time work and 14.1% were in part-time work. overall, 77.4% (1,640/2,108) of respondents reported being worried about the covid-19 outbreak in the uk. for those that had not previously tested positive for covid-19, 47.5% (979/2,108) believed that it was likely they would be infected at some point in the future under the uk government's preventive measures. if infected, just over half (56.9%) of respondents would expect to be moderately severely affected (e.g. may need self-care and rest in bed) (table 1) . accordingly, 94.2% of adults reported taking at least one preventive measure (to protect oneself and others) against covid-19 infection: 85.8% washed their hands with soap more frequently; 56.5% avoided crowded areas; 54.5% avoided social events and 39.2% avoided public transport (figure 1 ). most reported that their behaviour change was in response to government guidance (71.3%). preventive measures perceived to be most effective were washing hands more frequently with soap and water (92.5%), avoiding contact with people who have a fever or respiratory symptoms (91.4%), and covering nose and mouth when sneezing or coughing (90.0%) (figure 1 ). perceived effectiveness of preventive measures was higher than actual adoption for all measures. this was particularly marked for social distancing measures (figure 1 ). overall, 45.2% of respondents reported adopting social distancing measures (avoiding crowded places and avoiding social events) to protect themselves or others from covid-19. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/10.1101/2020.04.01.20050039 doi: medrxiv preprint . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint those that report avoiding crowded areas and social events; b mutually adjusted for age, sex, marital status, employment status, household income, savings and housing tenure; c adjusted for age, sex, marital status and employment status. d excluding those who responded "don't know"; e mutually adjusted for age, ethnicity, uk area of residence, household income, savings and housing tenure; f adjusted for age, ethnicity, uk area of residence and housing tenure; £ adjusted for age, ethnicity and uk area of residence. *p<.05, **p<.01, ***p<.001 overall, 44.3% of respondents reported being able to work from home (i.e. permitted by their employer and have the necessary equipment to do their job from home). respondents who held post-secondary but below degree-level (47.7%; aor:0.58; 95% ci:0.41,0.82) and secondary or below level (29.4%; aor:0.29; 95% ci:0.21,0.39) education qualifications were less likely to be able to work from home compared with those educated to degree level (62.6%) ( table 2) . as with educational level, there was a household income and savings gradient with ability to work from home. those with the lowest household income (<£20,000) were six times less likely to be able to work from home compared to those with household incomes of £50,000 and above (22.7% vs. 67.3%; aor:0.16; 95% ci:0.09,0.26). respondents with £100 savings or less were three times less likely to be able to work from home compared to those with £25,000 or more in savings (33.1% vs. 59.9%; aor:0.33; 95% ci:0.21,0.52) ( table 2) . compared with those who owned their home outright, those renting accommodation from a local authority or housing association were less likely to be able to work from home (18.2% vs. 41.0%; aor:0.37; 95% ci:0.18,0.75). overall, perceived ability (87.0%) and willingness (87.6%) to self-isolate for 7 days if asked by a healthcare professional were high. in terms of socio-demographic associations, there was no effect of sex on perceived ability to self-isolate (table 3) . however, women were somewhat more willing to do so than men (94.9% vs. 91.8%; aor:2.1; 95% ci:1.2,3.5). respondents from ethnic minority backgrounds perceived themselves to be less able to self-isolate than respondents from white backgrounds (84.8% vs. 92.1%, aor:0.47; 95% ci:0.27,0.82), although they were equally willing to do so (table 3) . some indicators of socioeconomic status were significantly associated with perceived ability and willingness to self-isolate. respondents who held post-secondary but below degreelevel education qualifications were less able (90.2% vs. 93.1%; aor:0.59; 95% ci:0.36,0.97) and less willing (90.9% vs. 94.9% aor:0.50; 95% ci:0.29,0.85) to self-isolate than respondents educated to degree level (table 3) . those with household incomes below . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/10.1101/2020.04.01.20050039 doi: medrxiv preprint excluding those who responded "don't know"; b mutually adjusted for age, gender, ethnicity, marital status, education, employment status, household income, savings, and housing tenure; c adjusted for age gender, ethnicity, marital status, employment status and housing tenure; d adjusted for age, gender, ethnicity, marital status, and employment status; *p<.05, **p<.01, ***p<.001 £20,000 were three times less likely to be able to self-isolate compared with those on household incomes of £50,000 and above (88.3% vs. 95.5%; aor:0.31; 95% ci:0.16,0.58). similarly, respondents with less than £100 in savings were three times less likely to be able to self-isolate compared with those with savings of £25,000 or more (84.8% vs. 95.6%; aor:0.35; 95% ci:0.18,0.68). there was no effect on willingness to self-isolate by household income or amount of savings (table 3) . those in accommodation rented from a private landlord, local authority, or housing association were less likely to report being able to self-isolate, although this association was no longer significant when other sociodemographic factors were adjusted for. in terms of willingness to self-isolate, respondents renting accommodation from a local authority or housing association (aor:0.39; 95% ci:0.21,0.75) and those living with parents, family or friends (aor:0.43; 95% ci:0.20,0.95) were less likely to be willing to self-isolate compared with those who owned their home outright (table 3) . this study reports on the perceptions and behaviour of the uk adult population in the two days following the government introduction of recommendations on social distancing (6). we found high levels of self-reported behaviour change. notably, the most-adopted measures, washing hands more frequently with soap and water, using hand sanitiser and covering nose and mouth when sneezing or coughing, prominently featured in national public health campaigns from relatively early on in the epidemic (4) and mirrors results seen in previous pandemics (13) . however, there were marked differences between the perceived effectiveness and adoption of npis. this suggests that lack of knowledge on what measures are effective against covid-19 is not a key driver of compliance in the uk population. in contrast, a similar study conducted in hong kong showed comparatively high perceived effectiveness and adoption of preventive measures (11) . our results highlighted significant differences across demographic and socio-economic strata for social distancing behaviour, ability to work from home, and the ability and willingness of people to self-isolate. adoption of social distancing measures was almost twice as likely in people over 70 compared to adults aged 18 to 34 years. notably, those that were single were less likely to practice social distancing. there was a strong association between socioeconomic deprivation and ability to adopt npis. although willingness to self-isolate . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/10.1101/2020.04.01.20050039 doi: medrxiv preprint was high overall, those from more disadvantaged backgrounds were less likely to be able to work from home or self-isolate if needed, suggesting the existence of structural barriers to adopting preventive behaviours in these groups. the strength of this study is in the representative sample of the uk adult population, the ability to achieve our sample size quickly, and the timeliness in relation to changing government recommendations. this study has three limitations. first, with an online approach, responses of those without internet access were under-represented. second, the survey tool consisted of predominantly closed-ended questions. thus, we were unable to explore responses in more depth. third, surveys collecting self-report data are generally subject to limitations including honesty, introspective ability and interpretation of the questions. our findings highlight the stark choices faced by those in lower socio-economic groups and suggest that unless the government intervenes to support these individuals, the impact of this epidemic will likely be felt unequally in our society. not only this, but if a large proportion of the population continues to work while unwell, low compliance will render the various forms of social distancing less effective, as low-income workers are forced to choose between financial and physical health. indeed, this behaviour has already been observed in the workplace in previous pandemics: workers without access to paid sick leave were more likely to work while unwell than those with paid sick leave (14) . a study in china after the h7n9 epidemic found that only 7% of people reported willingness to self-quarantine (15) . also, during the middle east respiratory syndrome (mers) outbreak in korea in 2015, there was heterogeneous uptake of preventive interventions (16) . in the absence of a vaccine and treatments over the short-term, high compliance with social distancing, self-isolation and household quarantine is paramount to reduce transmission and the impact of covid-19. and as the epidemic evolves, it is likely that compliance with preventive behaviours will continue to evolve too. npi compliance, risk perception and behaviour are not consistent across cultures, social status or time. indeed, previous studies have shown that perceptions and behaviours often change over time (13) . therefore, current modelling projections of the impact of npis on morbidity and mortality are always provisional (7) . future covid-19 models should explore the variation captured in this and . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint . https://doi.org/10.1101/2020.04.01.20050039 doi: medrxiv preprint previous studies to better estimate the impact of differential uptake of npis in the uk and beyond. it is also important to monitor behaviour throughout the epidemic to know when to implement further public health messaging, and when further or alternative government actions might be required, to mitigate falling compliance. our findings highlight that those most economically disadvantaged in society are less able to comply with certain npis, likely in part due to their financial situation. whilst one approach may be to better tailor public health messaging to this subpopulation, this must be done alongside considered fiscal and monetary policy to mitigate the financial costs of following government public health advice. therefore, it is imperative that the uk government, and governments around the world, quickly develop and implement policies to support the most vulnerable, in a bid to minimise the long-term social and economic harm caused by covid-19. government policy should recognise the disparity in impact across socio-economic groups, particularly across the labour market, and should aim to support workers equitably across the income spectrum. this would likely help increase compliance across the population to the levels required to suppress transmission and thereby reduce the strain on national health services, both in the uk and abroad. although the uk government has since announced a range of measures to support public services, individuals and businesses in part to facilitate compliance with current lockdown measures (17), it is uncertain how long these protections will be in place for and whether they will continue once lockdown restrictions are lifted. in summary, the population's response to public health advice is currently the key factor in tackling the covid-19 epidemic and whether the curve is flattened sufficiently to allow health services to cope (7) . factors affecting uptake and compliance with preventive measures are critical. those from socioeconomically more deprived backgrounds, in particular, may need further financial assurance and assistance from the government to be able to implement some of these measures, such as self-isolation. organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. the lead authors (cja and hw are the manuscript's guarantors) affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and any discrepancies have been explained. . cc-by-nc 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not peer-reviewed) the copyright holder for this preprint . https://doi.org/10.1101/2020.04.01.20050039 doi: medrxiv preprint the imperial college london research ethics committee approved the study (ref 20ic5861). informed consent was obtained from those who chose to complete the survey after having read introductory information on its content and purpose. the survey instrument is freely available to download from the school of public health, imperial college london covid-19 resources webpage: https://www.imperial.ac.uk/mrcglobal-infectious-disease-analysis/news--wuhan-coronavirus/covid-19-resources/ the data used for the analyses are publicly available from the corresponding author on request. coronavirus disease 2019 (covid-19) pandemic: increased transmission in the eu/eea and the uk -seventh update stockholm number of coronavirus (covid-19) cases and risk in the uk 2020 new coronavirus: uk public health campaign launched covid-19) action plan 2020 impact of non-pharmaceutical interventions (npis) to reduce covid19 mortality and healthcare demand public response to uk government recommendations on covid-19: population survey esomar28: 28 questions to help online research buyers14 community responses during the early phase of the covid-19 epidemic in hong kong: risk perception, information exposure and preventive measures. medrxiv. 2020. 12. public_health_england. stay at home: guidance for households with possible coronavirus (covid-19) infection perceptions and behavioral responses of the general public during the 2009 influenza a (h1n1) pandemic: a systematic review effectiveness of workplace social distancing measures in reducing influenza transmission: a systematic review public perceptions and reactions to h7n9 in mainland china preventive behavioral responses to the 2015 middle east respiratory syndrome coronavirus outbreak in korea the survey was conducted by yougov on behalf of the patient experience research centre, school of public health, imperial college london. questions were developed by the authors, and yougov provided suggestions to improve clarity and understandability. all authors have completed the icmje uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no financial relationships with any key: cord-011906-ek7joi0m authors: throuvala, melina a.; griffiths, mark d.; rennoldson, mike; kuss, daria j. title: mind over matter: testing the efficacy of an online randomized controlled trial to reduce distraction from smartphone use date: 2020-07-05 journal: int j environ res public health doi: 10.3390/ijerph17134842 sha: doc_id: 11906 cord_uid: ek7joi0m evidence suggests a growing call for the prevention of excessive smartphone and social media use and the ensuing distraction that arises affecting academic achievement and productivity. a ten-day online randomized controlled trial with the use of smartphone apps, engaging participants in mindfulness exercises, self-monitoring and mood tracking, was implemented amongst uk university students (n = 143). participants were asked to complete online preand post-intervention assessments. results indicated high effect sizes in reduction of smartphone distraction and improvement scores on a number of self-reported secondary psychological outcomes. the intervention was not effective in reducing habitual behaviours, nomophobia, or time spent on social media. mediation analyses demonstrated that: (i) emotional self-awareness but not mindful attention mediated the relationship between intervention effects and smartphone distraction, and (ii) online vigilance mediated the relationship between smartphone distraction and problematic social media use. the present study provides preliminary evidence of the efficacy of an intervention for decreased smartphone distraction and highlights psychological processes involved in this emergent phenomenon in the smartphone literature. online interventions may serve as complementary strategies to reduce distraction levels and promote insight into online engagement. more research is required to elucidate the mechanisms of digital distraction and assess its implications in problematic use. attentional focus is one of the most fundamental resources and a key to successful and high-order work [1] . in the attention economy [2] , multiple online and offline activities compete for an alternative share of attention [3] . this trend is expected to grow in the face of increasing communication complexity and information overload [4] , which is becoming even more prevalent partially due to the vast online accessibility, immediacy and convenience of smartphones, acting as a major motivational pull for engagement [5] and prompting constant multitasking and frequent attentional loss [6] . there are currently more than 3.5 billion smartphone users [7] and smartphone use is an emergent area of research [8] [9] [10] . emerging evidence on cognitive function has shown that smartphone availability and daily interruptions compete with higher-level cognitive processes creating a cognitive interference effect [11] [12] [13] [14] [15] , associated with poorer cognitive functioning [16] [17] [18] [19] , performance impairments in daily life [20] and potential supplanting of analytical thinking skills by "offloading thinking to the device" [21] (p. 473). in spite of such initial evidence, there are cognitive correlates within the digital wellbeing apps or mhapps (apps that track an individual's behaviour, i.e., time spent online, or that aid cognitive, emotional and/or behavioural wellbeing) [96] have been suggested as supporting self-awareness and self-regulation [97] and utilized in mental healthcare given their functionality, accessibility, higher adherence rates, real-time assessment, low-cost and for their intervention potential [98, 99] . the literature suggests that evidence-based apps may be efficacious in raising self-awareness, mental health literacy and wellbeing, self-efficacy, and ability to cope [96, [100] [101] [102] . online psychological interventions are becoming more prominent in the digital age [103] , rendering numerous positive health outcomes [102, [104] [105] [106] [107] [108] , complementing service provision and recognized by governmental health institutions (e.g., national institute for health and care excellence (nice) in the uk) [109] . however, more research is required to determine the comparative effectiveness of these therapies and their components [110] in improving mental health and wellbeing and rigorous objective evaluation beyond their developers is required. to date, there have been a small number of internet-based interventions associated with device use in university settings. distraction is not considered a dysfunctional construct by itself, but has been implicated in emotion regulation, adhd, and other disorders [111] [112] [113] , and has been minimally examined in the context of the digital environment with no evidence to date as to strategies that could ameliorate its occurrence [114] . therefore, the aim of the present study was to test the preliminary efficacy of an online intervention based on cognitive behavioural principles (i.e., self-monitoring, mood tracking, and mindfulness) to reduce distraction and related psychological outcomes (i.e., stress) among university students. given: (i) young adults are keen users of smartphone apps, with increased vulnerability to self-regulation and technology use [74] , (ii) the high stakes for academic achievement, and (iii) the similarity in processes observed between gambling addiction and social media overuse [115] , the strategies of mindfulness, activity monitoring, and mood tracking utilized in gambling harm-reduction [86, 116, 117] are employed in the present study. these strategies were delivered and facilitated through the use of smartphone mhapps and were tested for their efficacy in reducing levels of distraction and related psychological outcomes and their role in inducing changes in wellbeing [118] [119] [120] . the following hypotheses were formulated: hypothesis 1 (h1). compared to the control condition at follow-up, students receiving the intervention would report: (i) lower rates of smartphone distraction, smartphone and social media use duration, impulsivity, stress, problematic social media use, fomo and nomo and (ii) higher levels of mindful attention, emotional self-awareness, and self-efficacy. hypothesis 2 (h2). at follow-up, high distractors (hds) compared to low distractors (lds) (based on a median-split analysis) would show a greater reduction in distraction and significant improvement in outcomes. hypothesis 3 (h3). the intervention will mediate the relationship between (i) mindful attention and smartphone distraction, and (ii) emotional awareness and smartphone distraction. additionally, online vigilance will mediate the relationship between smartphone distraction and problematic social media use. to the authors' knowledge and given the novelty of the construct of smartphone distraction, this is the first study to examine a preliminary online randomized controlled trial via mhapps for the reduction of smartphone distraction. the present study fills a gap in the smartphone literature by assessing the efficacy of engaging with behaviour change strategies (i.e., mindfulness, self-monitoring, and mood-tracking) used successfully in gambling harm prevention for the reduction of distraction. the present study tested the efficacy of a ten-day online app-delivered randomized controlled trial (rct) based on cognitive-behavioural principles to reduce distraction (primary outcome) and a number of secondary psychological outcomes: self-awareness, mindful attention, fomo, anxiety, and depression among university students. rcts are considered the gold standard in intervention effectiveness despite limitations addressed by scholars [121, 122] , primarily for the lack of external validity or methodological choices [123] . a pragmatic psychosocial intervention with an rct design was chosen [124] . the duration of the intervention was set given a pragmatic consideration of the free use period of one of the apps (headspace) and, secondly, due to the preliminary nature of this investigation. consolidated standards of reporting trials (consort) guidelines were followed in the protocol and the procedures and reporting of the intervention [125] . the intervention involved the active engagement for the period of ten consecutive days with three smartphone apps serving three different functions: to assess smartphone and social media use, conduct mindfulness sessions with an emphasis on eliminating distraction, and track mood and assess its impact on distraction, stress, self-regulation, and other measures. interaction with apps was encouraged to: (i) raise emotional awareness of common mood states, such as feeling down, worried, or stressed through mindfulness, (ii) guide basic smartphone monitoring, focusing skills, and awareness, and (iii) provide insight through mood tracking (table 1) . to further support active engagement with these intervention components, eligible participants were asked to keep a daily online activity log for the duration of the intervention (i.e., the number of screen-unlocks and the time of day and number of minutes for which the smartphone was used, usefulness of apps, etc.), to aid time perception of daily activities, raise awareness levels, and help increase the accuracy of self-reporting and adherence to the intervention [126, 127] . promoting self-awareness of media use and understanding of own behaviour was a key target of the intervention in order to curb distraction. the study was reviewed and approved (no. 2018/226) by the research team's university ethics committee. daily reminders and messages via blogging were sent as a reminder to maintain routine and reflect on levels of activity [126, 137] . participants were recruited using convenience and snowball sampling techniques. after gaining institutional ethical approval, the study was advertised to students through the research credit scheme, in university lectures and labs, and to the public through social media as an online intervention to assess the reduction of smartphone distraction. this experimental intervention demanded a significant time involvement and offering incentives increased the chances of participation and completion of the full ten-day intervention. in return for participation, students were offered either research credits or entry in a prize draw (£50 gift cards). participants were included in the study based on two screening criteria: regular smartphone and social media usage. only those affirming both and granting consent were able to continue with participation. following the completion of the survey, participants were allocated to one of the two conditions (intervention [ig] or control [cg] ) and further instructions for participation in the intervention were provided depending on the allocation condition. after initially providing age and gender demographics, participants responded to survey items regarding habitual smartphone and social media behaviour (estimates of duration of use), smartphone distraction severity, trait self-regulation, trait mindfulness and other psychological constructs (detailed in "materials"). the survey took approximately 25 min to complete. a total of 261 participants were recruited who participated in the baseline assessment. of these, 155 were undergraduate psychology students in the uk (59.3%). the sample comprised 47 males (18%) and 214 females (82%), with an age range of 18 to 32 years (m = 20.72, sd = 3.12). figure 1 depicts the flow of participants through the study procedures. after the baseline assessment, during the intervention period two individuals of the intervention group withdrew from the study and were not considered in the analysis. from the 259 remaining participants, seven were removed due to providing 90% incomplete data. the final sample considered at baseline was 252 participants (intention to treat (itt) group) and included 123 participants in the intervention group and 129 in the control group. participants who completed both assessments were considered in the per-protocol analysis (pp) (n = 143, 56% of the original sample), with 72 participants comprising the ig and 71 participants the cg. between the two groups, as standardising can easily distort judgements of the magnitude of an effect (due to changes to the sample sd but not the population sd, which may bias the estimate of the effect size measure, such as cohen's d) [178] . as cohen's d has been reported in other rct and pre-post intervention studies, cohen's d was estimated [179] . finally, because the sample sizes of the two groups were unequal, type iii sums of squares were used for the ancova. to test the third hypothesis and the hypothesized psychological mechanisms underlying the intervention results, three different mediation analyses were performed across the chosen psychological constructs using spss statistics (version 25) and process (model 4; [180] [181] [182] [183] ), using a non-parametric resampling method bootstrap with 5000 bootstrapped samples and bias-corrected 95% confidence intervals, to probe conditional indirect effects for the variables examined. these analyses were performed on the itt sample in post-intervention results. the survey consisted of sociodemographic and usage data (questions related specifically to smartphone and social media use [hours per day]). the demographic questions and user-related questions had open responses (i.e., "how many hours per day do you use social media?"). the following scales were used for the psychological measures of the study: the smartphone distraction scale [138] is a newly developed scale comprising of 16 likert-type items. the scale comprises four factors: attention impulsiveness, online vigilance, emotion regulation, and multitasking. scores range from 1 (almost never) to 5 (almost always) with higher scores representing a greater degree of distraction. individual items on the test were summed to give composite scores. sample items included in the scale are the following: "i get distracted by my phone notifications", and "i constantly check my phone to see who liked my recent post while doing important tasks". the scale has demonstrated good psychometric properties [138] and excellent reliability in the present study with a cronbach's alpha of 0.90 for time 1 (t1) and 0.88 for time 2 (t2). the mindful attention awareness scale (maas) [139] is a 15-item assessment tool that assesses the dispositional tendency of participants to be mindful in everyday life and has been validated among young people, university students and community samples [139, 140] . item statements reflect experience of mindfulness, mindlessness in general and specific daily situations and are distributed across a range of cognitive, emotional, physical, interpersonal, and general domains. response options are based on a six-point likert scale from 1 (almost always) to 6 (almost never). scores were averaged across the 15 items to obtain an overall mindfulness score with higher scores reflecting higher levels of dispositional mindfulness. sample items include "i could be experiencing some emotion and not be aware of it until sometime later" and "i find it difficult to stay focused on what's happening in the present" and exhibited a high degree of internal consistency in the present study with a cronbach's alpha of 0.92 for t1 and 0.93 for t2. the emotional self-awareness scale (esas) [92] was used to assess esa and comprises five variables: recognition, identification, communication, contextualization, and decision making. the scale consists of 32 items (e.g., "i usually know why i feel the way i do") rated from 0 (strongly disagree) to 4 (strongly agree). the total esa score ranged from 0 to 128, and sub-scale items are combined to produce a composite score with higher scores indicating higher esa. the esas has presented reasonable internal consistency (cronbach's alpha = 0.72, 0.69, and 0.76 for pre-test, post-test and six-week follow-up) [92] . the scale has demonstrated good validity in prior studies [92, 101] and adequate internal consistency in the present study (cronbach's alpha of 0.87 for t1 and 0.86 for t2). the perceived stress scale (pss) [141] is one of the most widely used scales to assess perceived stress and the degree of unpredictability, uncontrollability, and burden in various situations. the scale used was the 10-item version rated from 0 (never) to 4 (very often) with sample items such as "in the last month, how often have you felt that you were unable to control the important things in your life?", and "in the last month, how often have you felt that you were on top of things?" scores are obtained by summing the items, with the higher score indicating more perceived stress. the scale possesses good psychometric properties [142] and its internal consistency in the present study was 0.86 for t1 and 0.83 for t2. the seven-item generalized anxiety disorder scale (gad-7) [143] is a brief clinical measure that assesses for the presence and severity of generalized anxiety disorder (gad). the self-report scale asks how often during the last two weeks individuals experienced symptoms of gad. total scores range from 0-21 with cut-off scores of 5, 10, and 15 being indicative of mild, moderate, and severe anxiety, respectively. increasing scores on the gad-7 are strongly associated with greater functional impairment in real-world settings. sample items are rated from 0 (not at all) to 3 (nearly every day) and sample items include: "feeling nervous, anxious or on edge" and "trouble relaxing". the scale has been widely used and considered a valid and reliable screening tool in previous research, presenting good reliability, factorial and concurrent validity [144, 145] , and demonstrated excellent internal consistency in the present study (α = 0.93 t1 and α = 0.90 for t2). the self-report behavioural automaticity index (srbai) [146] was used to assess habitual strength. the four-item scale was used to assess the degree of automaticity and contained items such as: "using social media on my smartphone is something . . . i do automatically" and "i start doing before i realize i'm doing it". participants indicate their agreement with each item on a likert scale ranging from 1 (does not apply at all) to 7 (fully applies). scores were averaged across items to obtain an overall habit score, with higher scores indicating stronger habitual smartphone use behaviour. the scale has been reported as psychometrically sound in previous studies with good reliability, convergent and predictive validity [146, 147] and demonstrated good internal consistency in the present study with a cronbach's alpha of 0.87 (t1) and 0.89 (t2). the generalized self-efficacy scale (gse) [148] is a widely used psychometric instrument comprising ten items that assess perceived self-efficacy ("i can always manage to solve difficult problems if i try hard enough."). items are rated on a four-point scale ranging from 1 (not at all true) to 4 (exactly true). the gse has demonstrated satisfactory internal consistency and validity across studies [149, 150] . cronbach's alpha in the present study was 0.90 (t1) and 0.88 (t2). the online vigilance scale (ovs) [46] is a 12-item likert scale which assesses a relatively new construct in the internet-related literature, referring to individuals' cognitive orientation towards online content, expressed as cognitive salience, reactivity to online cues and active monitoring of online activity. sample items include "my thoughts often drift to online content" and "i constantly monitor what is happening online". scale items are rated on a four-point likert scale from 1 (does not apply at all) to 4 (fully applies). higher mean scores indicate a higher degree of online vigilance. the scale has evidenced sound construct and nomological validity and high internal consistency [46, 49, 78] . the cronbach's alpha in the present study was 0.89 (t1) and 0.87 (t2). the eight-item barratt impulsiveness scale-alternative version (bis-8) [151] is a psychometrically improved abbreviated version of the 11-item bis scale [151] presenting good construct and concurrent validity in young populations [152, 153] . the scale assesses impulsive behaviour and poor self-inhibition and uses a four-point likert scale from 1 (do not agree) to 4 (agree very much). sample items include: "i do things without thinking" and "i act on the spur of the moment". cronbach's alpha coefficient in the present study was 0.85 (t1) and 0.86 (t2). the deficient self-regulation measure [154] is a seven-item scale assessing deficient self-regulation in videogame playing adapted for unregulated internet use [155] . the scale is rated on a seven-point likert scale from 1 (almost never) to 7 (almost always) and has demonstrated sound psychometric properties [154] . the scale was adapted for smartphone use with sample items such as "i would go out of my way to satisfy my urges to use social media" and "i have to keep using social media more and more to get my thrill". the original scale and its adaptation has presented satisfactory psychometric properties [154, 155] . the cronbach's alpha coefficient in the present study was 0.89 (t1) and 0.87 (t2). the bergen social media addiction scale (bsmas) [115, [156] [157] [158] ] is a six-item self-report scale for assessing social media addiction severity based on the framework of the components model of addiction (salience, mood modification, tolerance, withdrawal, conflict, and relapse) [159] . each item examines the experience of using social media over the past year and is rated on a five-point likert scale from 1 (very rarely) to 5 (very often), producing a composite score ranging from 6 to 30. higher bsmas scores indicate greater risk of social media addiction severity. a sample question from the bsmas is "how often during the last year have you used social media so much that it has had a negative impact on your job/studies?" a cut-off score over 19 indicates problematic social media use [160] . the bsmas has presented sound psychometric properties [115, [156] [157] [158] with high internal consistency (α = 0.82) [161] . the cronbach's alpha in the present study was 0.91 (t1) and 0.87 (t2). the fear of missing out scale (fomos) [162] includes ten items and asks participants to evaluate the extent to which they experience symptoms of fomo. the scale is rated on a seven-point likert scale from 1 (not at all true) to 5 (extremely true of me). the statements include: "i fear others have more rewarding experiences than me... i get anxious when i don't know what my friends are up to...it bothers me when i miss an opportunity to meet up with friends...". a total score was calculated by averaging the scores, with higher mean scores indicating a greater level of fomo. this instrument has demonstrated good construct validity [162, 163] , and good internal consistency with cronbach's alphas of α = 0.93 [164] and 0.87 [64] with α = 0.87 in the present study. the nomophobia questionnaire (nmp-q) [165] comprises 20 items rated using a seven-point likert scale from 1 (strongly disagree) to 7 (strongly agree). total scores are calculated by summing up responses to each item, resulting in a nomophobia score ranging from 20 to 140, with higher scores corresponding to greater nomophobia severity. nmp-q scores are interpreted in the following way: 20 = absence of nomophobia; 21-59 = mild level of nomophobia; 60-99 = moderate level of nomophobia; and 100+ = severe nomophobia. the scale has demonstrated good psychometric properties [165, 166] with cronbach's alphas of 0.94 [165] and 0.95 [167] . in the present study, internal consistency was: 0.89 for (t1) and 0.88 for (t2) respectively. the intervention initially involved the search and identification of appropriate mobile apps (in both the apple itunes store and the android google play store) for daily self-monitoring of social media activity for mindfulness practices and mood tracking. the apps needed to be freely available in order to be accessible by the participants. due to time limitations, the development of an app that would encompass all three features (mindfulness of distraction, self-monitoring, and mood-tracking) was deemed adequate for the study given the ample availability of well-designed products offering these services. the following three freely available smartphone lifestyle apps were utilized: (i) antisocial (screen time): to self-monitor screen time/social media use and for voluntary self-exclusion (block app after time limit is reached), (ii) headspace (mindfulness): brief mindfulness sessions, (iii) pacifica (mood tracking): the app encouraged monitoring and tracking an individual's emotional state at various times during the day to enhance awareness. at the outset of the study, participants were directed to an information statement followed by the digital provision of informed consent before responding to the questions. at the end of the survey, they were automatically assigned through the automatic randomization procedure used by the online survey platform qualtrics to either an intervention or a control group. therefore, the intervention was double-blind (to participants and investigators). participants assigned to the ig were asked to download the apps onto their smartphones and to actively engage with all three apps daily for 10 days, which was the maximum free period offered by one of these apps. participants were encouraged to engage with mindfulness/focusing exercises to track their emotional state during the day and monitor patterns in their wellbeing as well as report daily on smartphone usage rates. thereafter, participants received daily notifications via email for the duration of the intervention to remind them to provide online reports about their own social media usage rates, apps accessed, checking frequency, potential self-restriction from use, and satisfaction with the intervention. this process was used to motivate engagement with the apps and accountability. efficacy was evaluated by having a cg condition where participants did not engage in any app use and only completed assessments on the first and tenth day. the target of the intervention was to induce a more mindful state, raise awareness of media and smartphone use, enhance self-regulation and therefore reduce distractions and time spent on smartphones and indirectly on social media by using these apps. the sample size for the rct was determined a priori using g*power v.3 software for the expected increased effectiveness of the intervention compared to control on the primary outcome distraction at post-assessment (t2). empirical reviews [168] have suggested a median standardised target effect size of 0.30 (interquartile range: 0.20-0.38), with the median standardised observed effect size 0.11 (iqr 0.05-0.29). the present study was a low-threshold intervention for a non-clinical population, so a mean effect of d = 0.30 was expected. with a power of 1-ß = 0.8, and a significance level of α = 0.05, the sample size was calculated to be n = 95 participants per group to find between-and within-group effects. to account for attrition rates in online interventions and control for both type i and ii error rates, n = 125 participants per group were targeted for recruitment [169] . all data were analysed through spss v.25 (chicago, il, usa). preliminary data analyses included examining the data for data entry errors, normality testing, outliers, and missing data. seven cases were treated with listwise deletion due to a very high percentage of incomplete data at baseline, resulting in a final sample size of 252. for the rest of the dataset, little's missing completely at random (mcar) test showed that data were missing completely at random (p = 0.449). multiple imputation was used to complete the dataset for the baseline analysis and for the non-completers from post-intervention assessment based on patterns of missingness. the data were also checked to ensure that all assumptions for the outlined statistical analyses were satisfied. the kolmogorov-smirnov test was used to evaluate the normal distribution of the variables, and skewness and kurtosis values were examined. for both assessments, all self-report data were normally distributed. assumptions of t-tests included normality, homogeneity of variance, and independence of observations. violations of the assumption of homogeneity of variance were tested using levene's test of equality of variances [170] . descriptive statistics were conducted to summarize the demographic characteristics of the sample as well as scores for the self-reported and performance-based measures of interest (i.e., stress). pearson's correlations examined bivariate relationships between smartphone distraction and psychological variables, and frequency of smartphone and social media use (presented in table 3 ). while allocation randomisation aimed to reduce any differences between the groups at baseline, a series of independent sample t-tests for the continuous variables and chi-square tests for the categorical variables (gender, ethnicity and education and relationship status) were conducted to analyse group mean differences and compare the baseline and post-intervention outcomes for the control and intervention groups. these were also applied at post-intervention outcomes for both the control and the intervention group. a decrease from the baseline to the post-intervention assessment was hypothesised for the primary outcomes of smartphone distraction, stress, anxiety, deficient self-regulation, fomo and nomo and an increase was hypothesized for mindful attention, self-awareness and self-efficacy. following the descriptive analysis, data from the baseline and post-intervention assessments were analysed to test each of the hypotheses provided to inform the assessment of the intervention efficacy. two approaches to analysis were adopted. first, to isolate any effect of the intervention, a per-protocol (pp) analysis was conducted to maintain the baseline equivalence of the intervention group produced by random allocation [171] . however, given the limitations to this first analysis approach and to minimise biases resulting from noncompliance, non-adherence, attrition or withdrawal [172, 173] , analysis was performed also on an intention-to-treat (itt) basis [172] . however, these results were not reported in the present study. the effects of the intervention were assessed with an analysis of covariance (ancova), with a minimum significance level at p < 0.05. ancova was chosen given that it is quite robust with regard to violations of normality, with minimal effects on significance or power [174, 175] with any differences between the groups at baseline, for the various assessments being used as covariates in the model and considered artefacts of the randomisation [176] . co-varying for baseline scores supported the analysis in two ways. first, while randomisation aimed to reduce any pre-intervention differences between the groups, residual random differences may have occurred. accounting for such differences isolated the effect of the intervention. partial eta-squared were used as measures of strength of association [177] . to better understand the effect size of the intervention, it has been recommended to use the differences in adjusted means (standardized mean difference effect sizes) between the two groups, as standardising can easily distort judgements of the magnitude of an effect (due to changes to the sample sd but not the population sd, which may bias the estimate of the effect size measure, such as cohen's d) [178] . as cohen's d has been reported in other rct and pre-post intervention studies, cohen's d was estimated [179] . finally, because the sample sizes of the two groups were unequal, type iii sums of squares were used for the ancova. to test the third hypothesis and the hypothesized psychological mechanisms underlying the intervention results, three different mediation analyses were performed across the chosen psychological constructs using spss statistics (version 25) and process (model 4; [180] [181] [182] [183] ), using a non-parametric resampling method bootstrap with 5000 bootstrapped samples and bias-corrected 95% confidence intervals, to probe conditional indirect effects for the variables examined. these analyses were performed on the itt sample in post-intervention results. the t-test results for the pre-test scores found no significant differences between the groups, indicating independence. the post-test scores were significantly lower in the intervention group. for the smartphone distraction scale, the mean pre-test score was 58.06 (sd = 7.69) for the intervention group and 59.72 (sd = 8.08) for the control group. the mean post-test score was 39.70 (sd = 17.67) for the intervention and 58.78 (sd = 17.47) for the control group, respectively. the pre-test score mean was not significantly different between groups (t = −0.70, ns), but the post-test score mean was significantly lower for the intervention group than for the comparison group (t = −6.69, p < 0.001). the pattern was similar in the results for the other variables except for nomo, habitual behaviour, and social media use per day. table 2 provides a summary of the baseline t-test and chi-square outcomes and internal consistency for each scale at each measurement period. all scales demonstrated good internal consistency for the sample considered. a series of bivariate pearson's r correlation analyses was conducted to examine the results obtained amongst sds and the secondary outcomes (table 3) . smartphone distraction correlated significantly with problematic social media use (r(252) = 0.63, p < 0.01), anxiety (r (252) = 0.46, p < 0.01), online vigilance (r (252) = 0.51, p < 0.01), automaticity (r (252) = 0.57, p < 0.01), impulsivity (r(252) = 0.45, p < 0.01), deficient self-regulation (r(252) = 0.33, p < 0.01), smartphone use/day (r(252) = 0.31, p < 0.01), p < 0.01), fomo (r(252) = 0.28, p < 0.01) and nomo (r(252) = 0.51, p < 0.01). however, smartphone distraction correlated negatively with two variables: mindful attention (r(252) = −0.52, p < 0.01) and self-awareness (r(252) = −0.34, p < 0.01). to test h1 and assess the effect of the intervention on smartphone distraction, two separate ancovas were conducted. first, to isolate any effect of the intervention, a per-protocol analysis was conducted. as depicted in table 4 online vigilance (r (252) = 0.51, p < 0.01), automaticity (r (252) = 0.57, p < 0.01), impulsivity (r(252) = 0.45, p < 0.01), deficient self-regulation (r(252) = 0.33, p < 0.01), smartphone use/day (r(252) = 0.31, p < 0.01), p < 0.01), fomo (r(252) = 0.28, p < 0.01) and nomo (r(252) = 0.51, p < 0.01). however, smartphone distraction correlated negatively with two variables: mindful attention (r(252) = −0.52, p < 0.01) and self-awareness (r(252) = −0.34, p < 0.01). to test h1 and assess the effect of the intervention on smartphone distraction, two separate ancovas were conducted. first, to isolate any effect of the intervention, a per-protocol analysis was conducted. as depicted in table 4 ancova analyses for the secondary outcomes were also tested across both pp and itt samples. specifically, for the pp sample, main effects of the experimental group on post-intervention outcomes after controlling for baseline scores were found for self-awareness (f(1, 140) in order to evaluate the effects of the intervention in the intervention group based on level of distraction and to assess whether the effects were consistent in the intervention group independent of degree of distraction, participants were classed into two categories of high distractors vs. low distractors depending on perceived distraction level. a median-split analysis with high vs. low distractor levels was determined by scores above vs. below the median and these were separately analysed inside the intervention group. therefore, a two-way mixed anova with time (pre-test and post-test) as within-factor and distraction severity (high and low distraction) as between-factor was performed to investigate the impact of the intervention (time) and degree of distraction (high vs. low) as assessed at baseline on distraction levels at post-intervention. this analysis was conducted only for the dependent variable for which the interactions were found to be significant. results more specifically for mediation 1, the intervention group was the proposed independent variable in these analyses, mindfulness was the proposed mediator, and smartphone distraction was the outcome variable. for mediation 2, stress was the proposed independent variable in these analyses, online vigilance was the proposed mediator, and smartphone distraction was the outcome variable. for mediation 3, smartphone distraction was the predictor, social media addiction was the outcome and online vigilance was the mediator. analysed variables included the t1 scores on the constructs examined as covariates to account for pre-intervention performance. for mediation 1, it was hypothesized that mindful attention would mediate the relationship between the intervention and smartphone distraction ( table 5) . no mediation effect was found for mindful attention on the variables. however, a main effect of the intervention on smartphone distraction (path a: b = −0.67, t = −8.23, p < 0.001) was found, but no main effect of mindful attention on smartphone distraction (path b; b = 1.16, t = 0.67, ns). table 5 . mediation effects of mindful attention and emotional self-awareness on intervention effects and smartphone distraction and of online vigilance on smartphone distraction and social media addiction (n = 252). for mediation 2, it was hypothesized that self-awareness would mediate the relationship between the intervention and smartphone distraction (table 5 ). an indirect effect was found on self-awareness on the variables (a × b: b = −2.02, bca ci = [−3.10, −1.59]), indicating mediation. the intervention significantly predicted self-awareness (path a; b = −6.78, t = −4.32, p < 0.001) and self-awareness significantly predicted lower levels of smartphone distraction (path b; b = 0.30, t = 4.02, p < 0.001). for mediation 3, it was hypothesized that online vigilance would mediate the relationship between distraction and social media addiction (table 5 ). an indirect effect was found on self-awareness on the variables (a × b: b = 0.02, bca ci = [0.01, 0.03]), indicating mediation. the intervention significantly predicted self-awareness (path a; b = −0.01, t = −3.32, p < 0.001) and self-awareness significantly predicted lower levels of smartphone distraction (path b; b = 1.66, t = 4.02, p < 0.001). the present study tested the efficacy of an online intervention employing an integrative set of strategies-consisting of mindfulness, self-monitoring and mood tracking-in assisting young adults to decrease levels of smartphone distraction and improve on a variety of secondary psychological outcomes, such as mindful attention, emotional awareness, stress and anxiety, and perceived self-efficacy, as well as to reduce stress, anxiety, deficient self-regulation, problematic social media use and smartphone-related psychological outcomes (i.e., online vigilance, fomo and nomo). results of the present study provided support for the online intervention effectiveness in impacting these outcomes. findings suggested that students receiving the intervention reported a significant reduction in the primary outcome of smartphone distraction, unlike students in the control group who reported a non-significant reduction in smartphone distraction. in terms of the secondary outcomes, participants in the intervention condition experienced a significant increase in self-awareness, mindful attention, and self-efficacy, and a significant decrease in smartphone use/day, impulsivity, stress, anxiety, deficient self-regulation, fomo, and problematic use. no significant results were found for social media use per day, habitual/automated use and nomo. according to the findings of the present intervention, it appears likely that practising mindfulness and monitoring mood and smartphone activity could lead to a desired behavioural change towards less distraction and less perceived stress with carry-over effects in self-awareness and self-efficacy, similar to interventions for other mental health problems [83, 85, 87, 91, 93, 184, 185] . these findings are consistent with the growing body of research indicating that mindfulness and self-monitoring are effective strategies to increase self-awareness and reduce stress [84] [85] [86] [87] [88] [89] [90] 186] . mindful attention could enhance awareness of individual media behaviour by: (i) raising understanding and awareness of disruptive media multitasking activities (i.e., predictors, patterns and effects), and (ii) raising awareness of different strategies for coping with digital distraction and of which strategies are most effective. second, self-monitoring could help in developing an understanding of media habits and time spent on smartphone and social media activities and could curb perceived excess smartphone interaction, consistent with other study findings [92, 101, 187, 188] . therefore, strategies employing increased mindfulness practice and self-monitoring could aid attentional capacity and self-awareness, which is considered a necessary condition in the behaviour change process of risky behaviours [189, 190] . third, mood tracking could enhance awareness of triggers of negative mood and ensuing negative emotional states acting as drivers for distraction. it appears that the same technologies which may impact negatively on young people may be used to leverage smartphone use [100] and deflect psychological distress if evidence-based behaviour change strategies are applied. intervention strategies such as mindfulness and self-monitoring may encourage increased self-awareness and thus help reduce distraction levels and increase mindful attention. the intervention was also successful in reducing secondary outcomes, such as stress levels and fomo, and it had a positive effect on emotion regulation and loss of control levels. distraction appears to be associated with higher access to social media content and is mediated by online vigilance. salience of smartphone-mediated social interactions (i.e., the salience dimension of online vigilance) has been found to be negatively related to affective wellbeing [49] . it has been reported that emotional dysregulation mediates the relationship between psychological distress and problematic smartphone use [191] . higher self-regulation online has been identified as a moderator between need to belong and problematic social media use in young people [192] and emotion dysregulation as a mediator between insecure attachment and addiction [193] . although distraction is an emotion regulation strategy with a protective function against emotionally distressing states [111] and dysphoric mood [194] , or is used for adaptive coping [195, 196] , deficits in attentional control, such as distraction, may also be implicated in stress, anxiety or other affective disorders [197] and in generalized anxiety disorder with core cognitive symptoms related to excessive thoughts and deficits associated with increased perseverative worry [198] . therefore, higher mindful attention and monitoring of mood may have influenced the reduction of distraction and the enhancement of emotional control. mediation analyses were also performed to understand the relationships between intervention effects on smartphone distraction via two mediators, mindful attention and self-awareness, and of online vigilance on the relationship between distraction and social media addiction. mediation effects were significant for the relationship among intervention effects and distraction via self-awareness, and for distraction and problematic social media use via online vigilance, indicating that self-awareness could be a potential behaviour strategy to mitigate distraction levels. however, the relationship among intervention effects and distraction was not significant via mindful attention as a mediator. therefore, in the present study it appeared that despite its statistically significant increase, mindful attention was not a mediating factor for distraction in the intervention. mindful attention could potentially be the vehicle to increasing emotional self-awareness [93, 184, 199] , prompting more controlled smartphone interactions. on the contrary, online vigilance was found to be a mechanism associated with smartphone distraction and problematic social media use, given the strong preoccupation with the content prompted even by the mere presence of smartphones, confirming previous findings [200] . therefore, despite its protective function, distraction may concurrently serve as a gateway to increased smartphone engagement and time spent on devices. time spent alone is not a defining factor and it has been argued instead that the interaction of content, context and time spent, as well as the meaning attached to these interactions, may determine the level of problematic media use [5, 201] . within smartphone use, distraction is a salient behaviour with evidence that distraction and mind-wandering are associated with online vigilance, which via reduced mindfulness may be associated with decreased wellbeing [78] . furthermore, inattention symptoms have been implicated in risk for smartphone addiction and problematic smartphone use [202] . therefore, handling distraction, which has neural correlates [203] , may be the means to resisting cue reactivity, implicated in smartphone addiction, in reduced cognitive performance [113] or in obsessive-compulsive symptoms [204] . further research is required to assess these cognitive and emotive dimensions of smartphone distraction and its effects on engagement in line with current trends [205] . however, it has been proposed that the construct of distraction extends beyond the debate on smartphone addiction by considering the role of the smartphone in coping with negative emotions and addressing preference for online vs. offline communications [206] . research is still conflicted in relation to the cognitive function of distraction. experimental smartphone research has provided initial evidence that social apps compared to non-social apps on smartphones do not capture attention despite their perceived high reward value [207, 208] , but other studies support a high interference effect [209] . therefore, more research is required to elucidate the mechanisms of digital distraction and delineate how digital technologies, individual choices, and contexts affect individuals' attention spans and attentional loss, as well as mental health conditions, such as adhd and anxiety and overall psychological wellbeing [210] . the present rct assessed the effectiveness of the impact of the use of mindfulness, self-monitoring, and mood tracking delivered through interaction with smartphone apps in reducing distraction arising from recreational smartphone use and social media use. the findings suggest that engaging with the aforementioned practices was effective in reducing distraction levels, stress, anxiety, deficient self-regulation, impulsivity and smartphone-related psychological outcomes, and improving mindful attention and emotional self-awareness and self-efficacy. some limitations need to be taken into consideration. first, a convenience sample of university students was used, which hinders the generalizability of the findings to other groups (i.e., older adults or children). however, this population was considered of primary interest for the study because university students are digital natives liable to experience negative academic consequences due to vulnerability to problematic smartphone use [211] . the effect sizes found in this rct were medium to large for the variables examined, exceeding the expected range for low-intensity, non-clinical interventions [212] . however, as a result of the main recruitment protocol, the intervention may have attracted participants who had an interest in the outcomes and a potential self-assessed vulnerability. therefore, the voluntary, self-selected nature of participation could have introduced a significant degree of participant response and confirmation bias [213] , resulting in the medium to high effect sizes. additionally, the high drop-out rates, consistent with other online rcts [214] , could have significantly affected the strength of the findings [215] , and the use of a passive control group might have led to an overestimation of the effects [216] . due to the use of market-available apps, actual adherence and engagement with the intervention was not accounted for, nor were reasons for dropout [217] . therefore, the findings should be treated with caution and replicated in future designs. future studies should systematically address response bias and include methods in the rct to improve the accuracy of self-reported data [218, 219] . combining self-report with behavioural data [220] , ecological momentary sampling [221] , psycho-informatics and digital phenotyping, the provision of a digital footprint for prognostic, diagnostic and intervention purposes [222] , could enhance the ecological validity of the study. equally, incorporating the measurement of brain activity using magnetic resonance imaging (mri) in interventions could greatly enhance accuracy of assessment of prevention efforts and understanding of the role of neurobiology in behaviour [223, 224] . the impact of the intervention on gender was not examined because this university student sample consisted mainly of female participants. considering the gender differences reported in smartphone use [48, 225] and in attention processes [226] , future studies should explore its effect, which could have significant implications for the intervention and prevention of attention failures and poor student outcomes [227] . additionally, the study design did not manage to provide a longer intervention period due to the lack of freely available apps for participants to use and did not include a second follow-up period to track maintenance of long-term effects, as is customary in rcts, or the use of qualitative process evaluation for a critical understanding of impact of the intervention components [228] . finally, social, economic and family conditions as well as other issues, which are critical to young people's psycho-emotional states and sense of identity, were not accounted for in the present study [229, 230] . despite these limitations, the study provides initial evidence for efficacy of strategies in curbing smartphone distraction and adds to the limited body of knowledge of cognitive-emotive processes in smartphone and social media use [205] . it also contributed to the still limited knowledge on interventions in smartphone distraction and constitutes a simple, first-step, low key intervention programme, which may be practised by individuals seeking support for attentional difficulties on a self-help basis or within a stepped-care clinical framework for prevention purposes [96] . experiencing distraction from smartphones and social media content, interferes with high-level cognitive processes and has productivity and emotional implications (i.e., stress) in various contexts and situations [51, [231] [232] [233] [234] , being further compromised by digital triggers and the structural design of smartphones prompting salience and reactivity [235] . these results have clinical implications as low-intensity interventions may prevent small scale emotional problems from developing into clinical disorders and can reduce incidences of mental health problems [236, 237] . practitioners may also find value in using mindfulness and monitoring practices as an adjunct to therapy for problematic use of smartphones. it may be of high value for academic institutions to build specific university-based programmes on maintaining balanced technology use, tackling unregulated and promoting positive smartphone use, or guiding students towards suitable methods to address attention problems more effectively [238, 239] . apps may also be utilized by schools for students that are faced with attentional/excessive use difficulties and in assisting young people to become aware of their emotions in preparation for learning more adaptive coping strategies. distraction is an emergent phenomenon in the digital era considering that the boundaries between work and recreation are increasingly blurred with both domains arguably dependent on the use of digital media [240] . more research on attentional processes within smartphone use could aid the understanding of these processes and impacts experienced across different age groups. psychological low-cost interventions may be effective in addressing precursors of problematic behaviours and enhancing wellbeing dimensions. the aim of the present study was to assess the efficacy of an rct combining evidence-based cognitive-behavioural strategies to reduce distraction from smartphone use, increase mindful attention, emotional self-awareness and self-efficacy and reduce stress, anxiety, deficient self-regulation and smartphone related psychological outcomes (i.e., online vigilance, fomo and nomo). second, it tested the mediating effect of mindful attention and self-awareness of the intervention on distraction, and of online vigilance on the relationship between distraction and social media addiction. findings suggested that students receiving the intervention reported a significant reduction in the primary outcome of smartphone distraction, whereas students in the control group reported a non-significant reduction in smartphone distraction. in terms of the secondary outcomes, participants in the intervention condition experienced a significant increase in self-awareness, mindful attention and self-efficacy and a significant decrease in smartphone use/day, impulsivity, stress and anxiety levels, fomo, deficient self-regulation and problematic social media use. no significant results were found for duration of social media use/day, habitual use and nomo. mediation effects of the intervention were also observed on distraction and problematic social media use via the mediators of emotional self-awareness and online vigilance in mitigating distraction levels. mindful attention was not found to be a mediating process for reducing distraction in the intervention. research on digital distraction is still scarce, yet there is increasing interest in cognitive impacts within digital environments. more evidence is required to assess the nature of attention failures and difficulties occurring both in normative and excessive online use. this evidence would allow an understanding of the prevalence and the nature of these difficulties, as well as their integration in intervention media literacy and risk prevention programmes, enhancing wellbeing, productivity and academic performance. the authors declare no conflict of interest. the forgotten frontier of attention cognition in the attention economy attention economies information and communication technology overload and social networking service fatigue: a stress perspective a 'control model' of social media engagement in adolescence: a grounded theory 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multimorbidity in europe? policy brief 22 icare4eu consortium understanding the determinants of digital distraction: an automatic thinking behavior perspective this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-331675-ipryt7o7 authors: itzchakov, guy; weinstein, netta; legate, nicole; amar, moty title: can high quality listening predict lower speakers' prejudiced attitudes?() date: 2020-08-06 journal: j exp soc psychol doi: 10.1016/j.jesp.2020.104022 sha: doc_id: 331675 cord_uid: ipryt7o7 theorizing from humanistic and motivational literatures suggests attitude change may occur because high quality listening facilitates the insight needed to explore and integrate potentially threatening information relevant to the self. by extension, self-insight may enable attitude change as a result of conversations about prejudice. we tested whether high quality listening would predict attitudes related to speakers' prejudices and whether self-insight would mediate this effect. study 1 (preregistered) examined scripted conversations characterized by high, regular, and poor listening quality. in study 2, we manipulated high versus regular listening quality in the laboratory as speakers talked about their prejudiced attitudes. finally, study 3 (preregistered) used a more robust measure of prejudiced attitudes to test whether perceived social acceptance could be an alternative explanation to study 2 findings. across these studies, the exploratory (pilot study and study 2) and confirmatory (studies 1 & 3) findings were in line with expectations that high, versus regular and poor, quality listening facilitated lower prejudiced attitudes because it increased self-insight. a meta-analysis of the studies (n = 952) showed that the average effect sizes for high quality listening (vs. comparison conditions) on self-insight, openness to change and prejudiced attitudes were, ds = 1.19, 0.46, 0.32 95%cis [0.73, 1.51], [0.29, 0.63] [0.12, 0.53], respectively. these results suggest that when having conversations about prejudice, high-quality listening modestly shapes prejudice following conversations about it, and underscore the importance of self-insight and openness to change in this process. theorizing from humanistic and motivational literatures suggests attitude change may occur because high quality listening facilitates the insight needed to explore and integrate potentially threatening information relevant to the self. by extension, self-insight may enable attitude change as a result of conversations about prejudice. we tested whether high quality listening would predict attitudes related to speakers' prejudices and whether self-insight would mediate this effect. study 1 (preregistered) examined scripted conversations characterized by high, regular, and poor listening quality. in study 2, we manipulated high versus regular listening quality in the laboratory as speakers talked about their prejudiced attitudes. finally, study 3 (preregistered) used a more robust measure of prejudiced attitudes to test whether perceived social acceptance could be an alternative explanation to study 2 findings. across these studies, the exploratory (pilot study and study 2) and confirmatory (studies 1 & 3) findings were in line with expectations that high, versus regular and poor, quality listening facilitated lower prejudiced attitudes because it increased self-insight. a meta-analysis of the studies (n = 952) showed that the average effect sizes for high quality listening (vs. comparison conditions) on selfinsight, openness to change and prejudiced attitudes were, ds = 1. 19, 0.46, 0.32 95%cis [0.73, 1.51], [0.29, 0 .63] [0.12, 0.53], respectively. these results suggest that when having conversations about prejudice, highquality listening modestly shapes prejudice following conversations about it, and underscore the importance of self-insight and openness to change in this process. high quality listening is the focal strategy of most therapeutic interventions (friedman, 2005) . in offering such listening the therapist aims to increase client introspection (gilbert, 2010; perls et al., 1951; rogers, 1951; vargas, 1954) , and it may be one of the primary reasons why, regardless of the specific modality, therapy generally helps people to change in a positive direction (lambert & barley, 2001) . outside of the therapy context, however, we know less about the benefits of highquality listening for helping people to change. the present paper explores the benefits of high quality listening outside of the therapeutic context to test the possibility that high quality listening might catalyze changes in one's attitudes -specifically lowering prejudiced attitudes. we posited that high quality listening can influence prejudiced attitudes by allowing individuals to introspect in an open-minded manner on the views they hold without fear of judgment, thus making it easier to be open to changing or modifying attitudes. the hypotheses are informed by the humanistic approach of carl rogers (rogers, 1951 (rogers, , 1980 , self-determination theory , and the nascent high quality listening literature (e.g., van quaquebeke & felps, 2018) . overall, this literature converges on a definition of high quality listening as listening that offers empathy (an understanding of the speaker's point of view), interest-taking, and unconditional regard (caring for the speaker, independent of expressed content and a non-judgmental stance). this operationalization of listening is aligned with the constructs of active and reflective listening (gordon, 1975; levitt, 2001) , and therapeutic listening (kemper, 1992) , all of which broadly share these same supporting features. judgmental climate in which hidden and contradictory experiences can be safely explored (rogers, 1951) . self-insight is defined as a deeper reflection and understanding about how one relates to the topic under discussion -and this downstream consequence is a primary goal of many psychotherapies seen to underlie behavioral and attitudinal change (e.g., bennett-levy & thwaites, 2007; connolly gibbons et al., 2007) . however, self-insight is important to differentiate from seemingly similar constructs present in the literature. insight has been studied at the dispositional level, though it is measured in terms of felt confusion about one's experiences alongside self-understanding (grant et al., 2002) . this formulation is sensible for dispositional measures where insight reflects a sense of clarity rather than disorder around the self (campbell, trapnell, heine, katz, lavallee, & lehman, 1996; morrison & wheeler, 2010) , but less relevant when the insight relates to exploring currently held biases, where the absence of the previous selfreflection, rather than confusion, per se, is likely driving biases (verplanken et al., 2007) . said another way, in the context of attitude change, self-insight matters insofar as it reflects a process of learning about oneself. consistent with this is theorizing within self-determination theory (sdt; that views high quality listening as an integral aspect of providing autonomy support -the support for people to act according to their values and beliefs. autonomy support is similar to high quality listening as conceptualized within the humanistic literature in that it involves demonstrating empathy and perspective-taking, encouraging interest taking in others' self-revelations, and providing unconditional regard . though high quality listening is a necessary ingredient of autonomy support, it has not been isolated from other qualities of providing autonomy support (such as providing people choices or a meaningful rationale; ryan & deci, 2017 ). yet sdt-based research offers evidence to support the expectation that high quality listening would promote self-insight in that autonomy support has been consistently shown to reduce defensiveness and increase introspection (caprariello & reis, 2011; hodgins & knee, 2002; hodgins et al., 2006; pavey & sparks, 2008 reis et al., 2018; reis et al., 2017) . furthermore, clients in therapy recognize these therapist qualitiesproviding a climate of empathic understanding and non-judgment -as the primary reason they are able to explore and self-disclose difficult material (bachelor, 1995; bedi, 2006) . especially salient for attitude change, high quality listening fosters openness and lowers defensiveness, which helps individuals gain insights about themselves, their emotions, cognitions, and values (abbass & town, 2013; lacewing, 2014) . furthermore, studies on mindful attention (haddock et al., 2017) describe that high attention is required for self-insight but place less focus on the learning and discovery qualities of interest here. we furthermore differentiate self-insight from insight about events, more broadly. self-insight has to do with knowing oneself, understanding one's own internal emotional and cognitive responses (dunning, 2012) , and with how the interpersonal exchanges foster this form of self-understanding (castonguay & hill, 2007) . furthermore, although self-insight has an interpersonal component in this project, in that it is expectedly elicited through conversation with a partner who is empathic, it is distinct from broader experiences of interpersonal comforts, such as psychological safety -feeling safe for interpersonal risk-taking (edmondson, 1999) , or identity security (tyler & blader, 2003 ), which do not involve self-reflection and self-learning. even outside of the context of psychotherapy, expressing difficult content such as negative attitudes, experiences, and emotions should also be sensitive to high quality listening because individuals may feel vulnerable, exposed, or judged. high quality listening is likely to reduce the defensiveness that can naturally arise when discussing negative attitudes and experiences . in the absence of such listening, the result is too often an attitude change in the opposite direction. in this case, speakers become more firmly entrenched in their original stance (boomerang effect; heller et al., 1973) because of the perceived threat (brehm, 1972) , which prompts processing of information in a defensive manner (kunda, 1990 ). in the interest of selfprotection, while each party is talking, the other party is mulling counter-arguments that would win the argument. on the contrary, when individuals experience high quality listening, they become more open-minded and process information in a less defensive and self-serving manner . furthermore, difficult and negative experiences, attitudes, and emotions may be particularly challenging to integrate or assimilate into self-knowledge or identity, because this knowledge itself elicits a defensive response and enters into a direct contradiction with other more positive content regarding the self (e.g., i am a caring person; freud, 1936; kegan, 1982; shedler, 2010; weinstein et al., 2011) . it has been theorized that for the integration of difficult and negative content to take place, individuals must have a willingness to take ownership, which is less likely to happen when defenses are high (weinstein et al., 2013) . self-insight is necessary for owning or integrating this new information into the self-structure (pennebaker et al., 1988; weinstein et al., 2013) . because negative attitudes and experiences may evoke people's defenses, it is important to reduce defensiveness in order to process and integrate potentially negative and threatening information. thus, lowering defensiveness is key for fostering self-insight (stotland et al., 1959) . when individuals feel defensive, they seek information to support their initial attitude (kunda, 1990) , reject and ignore new information (frey, 1986; jemmott et al., 1986) , process information in a biased manner itzchakov & van harreveld, 2018) and avoid the associated unpleasant emotions (weinstein & hodgins, 2009) in the service of self-protection. fundamentally, the defensive process is inherently aimed at and always prepared to manage perceived threats to the self (sherman & cohen, 2002) . defensive processes have also been closely linked to extreme views, such as those that may characterize prejudice (maio et al., 2010) . for this reason, it seems important to reduce defensiveness in order to allow people to reflect on their prejudices. indirect evidence comes from research on mindfulness, which is conceptualized as non-judgmental awareness of the present (kabat-zinn, 2015) . specifically, when individuals are mindfully aware of conflictual affect and self-relevant information they show more emotional differentiation (hill & updegraff, 2012) , better self-regulation (erbas et al., 2014) , and respond more positively to situations of uncertainty (haddock et al., 2017) . mindful attention has also been linked to changing stereotypes and prejudice (e.g., djikic et al., 2008; lillis & hayes, 2007; lueke & gibson, 2015) . of importance to the present research is recent empirical evidence showing that lower defensiveness could account for the associations between high quality listening and (reduced) attitude extremity . however, this particular study did not examine negative attitudes such as prejudice. the sdt literature suggests that when autonomy support is low, individuals have more prejudiced attitudes towards out-groups and show less desire to be in contact with them (fousiani et al., 2016) and this can be explained by increasing feelings of defensiveness (weinstein et al., 2012) . experimental evidence also supports the notion that autonomy-supportive contexts can reduce prejudice (legault et al., 2011) , though this support did not involve interpersonal interactions or listening. here, we investigated whether high quality listening allows individuals to introspect in a nondefensive, open-minded manner and therefore change prejudiced attitudes. we expected prejudice to be affected by listening largely because high quality listening in a conversation about prejudice allows people to self-reflect on their beliefs without fear of judgment. as prejudiced attitudes counter most people's deeply-held values for equality and inclusivity (amiot et al., 2012) , sdt theorizing would expect those deep-rooted core values to prevail over prejudiced attitudes that are not as well-internalized (assor, 2012; ryan & deci, 2017) . thus, when given space for self-reflection that is free of judgment and consequences, as is the case when providing high-quality listening, people will naturally be less inclined to hold onto prejudiced attitudes. it has been suggested that individuals must be willing to explore, recognize, and challenge their beliefs for their attitudes to change (zúñiga et al., 2002) . high quality listening may be a key to this type of self-insight rogers, 1951 rogers, , 1980 . recent work has found that a non-judgmental exchange of narratives in interpersonal conversations was more impactful in reducing exclusionary attitudes than providing arguments (kalla & broockman, 2020) . however, to the best of our knowledge, there has been no research isolating the effects of high quality listening on speakers' prejudiced attitudes, and very little work associating listening to attitude change of any kind. it is important to distinguish the present study from research that has examined the effects of perspective-taking on prejudice because perspective-taking and high quality listening might at first glance appear similar. perspective-taking is defined as a process where people try to adopt others' viewpoints to understand their needs, values, and preferences (parker & axtell, 2001) . previous work has found that encouraging people to take others' perspectives reduces the perspective takers' prejudice (galinsky & ku, 2004) . by contrast, the focus of the present study is on the person who expresses prejudiced attitudes, not the perspective-taker. said differently, perspective-taking research focuses on the effects on the listener (i.e., the perspective-taker) and is other-focused. in contrast, the present study focuses on the effects on the speaker (i.e., the perspective-giver) and the role that listening has on an inner focus through facilitating self-insight. furthermore, previous work has found that perspective-giving reduces prejudiced attitudes for members of the group with lower power when a member of the group with the higher power listens to them (bruneau & saxe, 2012) . the present research differs that the listener, whether imagined (study 1) or real (studies 2 & 3) was not a member of an outgroup. for these two reasons, the present studies are fundamentally different from other studies on the effects of intergroup contact on prejudice. furthermore, studies have not tested whether self-insight plays an exploratory role in explicating why listening may affect attitude change. to address this gap, the present research evaluated three hypotheses to explore the associations between high quality listening, selfinsight, and prejudiced attitudes (see fig. 1 ). hypothesis 1. as compared to poor (study 1) and regular (all studies) listening, high quality listening will increase speakers' self-insight. hypothesis 2. as compared to poor (study 1) and regular (all studies) listening, high quality listening will increase speakers' openness to change their prejudiced attitudes by increasing self-insight. hypothesis 3. as compared to regular listening (in studies 2 and 3), high quality listening will predict increased speakers' attitude favorability (i.e., lower prejudiced attitudes) towards the outgroup by encouraging self-insight and openness to change. we conducted a pilot study (reported in the supplementary material), and three experiments to empirically test these hypotheses using experimental paradigms that would allow largely causal interpretations of the data. building off of initial development of the paradigm in the pilot study, in study 1 (preregistered) scenarios instructed participants to imagine having a conversation about a negative bias that they have towards a particular group of their choosing, where their conversation partner demonstrated high quality listening behavior, regular listening behavior, poor listening, depending on assignment to conditions. in study 2 we increased the ecological validity of the experiments with a live conversation partner, contrasting high quality and regular listening. participants wrote about the group about which they had a negative bias and conversed about it in front of a listener who exhibited either good or regular listening behavior. finally, study 3 was a preregistered conceptual replication and expansion of study 2. specifically, participants rated their attitude towards five specific groups, wrote about the group towards which they had the strongest bias, and then conversed about it with either a good or regular listener. all manipulations and exclusions in the studies are disclosed, as well as the method of determining the final sample size. data collection did not continue after data analysis. studies 2 and 3 included other measures for separate work on well-being and self-determination theory (i.e., self-esteem, psychological need satisfaction). study 1 was a preregistered (http://aspredicted.org/blind.php?x= n8ab67) test of the three hypotheses summarized above. we used a confirmatory approach to test the effects of high quality listening as compared to a regular listening condition on measures of openness to change and self-insight. because the self-insight measure was new to this project (first tested in the pilot study), to substantiate the construct validity, we added an existing measure of reflective self-awareness (trapnell & campbell, 1999 ) as an additional assessment of self-insight. we recruited 461 israelis through an online platform similar to the one used in the pilot study. 2 of the initial sample, 14 participants provided meaningless answers to the question about their bias, and 62 failed to answer the awareness question, which we added to this study (i.e. "on this question, mark number 5"), and we excluded their responses. therefore, the final sample size was n = 385. power analysis using gpower (faul et al., 2007) indicated that this sample size has a power above 0.80 to detect the effect size on openness to change which was obtained in the pilot study; namely, cohen's f = 0.22 (converted from cohen's d = 0.44). the sensitivity analysis indicated that the weakest effect size detectable with this sample size and power of 0.80 was cohen's f = 0.15. a serial-mediation model of the effect of high quality listening on speakers' attitude favorability towards outgroup. 2 those who participated in the pilot study were not eligible to take part in study 1. g. itzchakov, et al. journal of experimental social psychology 91 (2020) 104022 5.1.2. procedure after completing consent forms, participants were asked to think about a negative bias (prejudice) they have towards a specific group. for this purpose, all participants received the following instruction (translated from hebrew): "please take a few minutes to think about any negative bias you may have or have had in the past towards a particular social group. most people will feel some kind of bias throughout their lives. bias is defined as negative feelings and thoughts about a group of people with a common characteristic." examples were provided to help orient participants to the kind of bias examined in this study (namely, prejudice towards out-groups), and to encourage participants to think concretely about what this bias might mean to them. afterward, participants were asked to write a short description of the bias they described. subsequently, participants read a scenario asking them to imagine having a conversation about the group they wrote about with another person. participants were randomly assigned to read a scenario describing their conversation partner as a high quality listener (n = 122), a poor quality listener (n = 149), or a regular listener as a comparison (n = 123). we asked participants to read the scenario twice. to ensure that participants did not skip the manipulation, survey software ensured they spent at least 50 s on the page before they were able to progress to the next page. participants in the high quality listening condition read the following scenario (translated from hebrew), which have been used in past experiments of high quality listening and included elements of empathic listening, unconditional positive regard, and interest-taking based on humanistic, motivational, and social psychological theorizing rogers, 1951; van quaquebeke & felps, 2018) : "imagine that you are talking about the negative bias you mentioned on the previous page with a person who has a neutral (neither positive nor negative) attitude towards this group. during the conversation, you feel that your conversation partner is really trying to understand your views and experiences relating to your negative bias in a non-judgmental way. moreover, his reactions, questions, and comments show you that he takes a genuine interest in you and your experiences -in what you have to say. during the conversation, your conversation partner seems empathic; he is attuned to your feelings behind the negative bias and shows an understanding of how difficult it can be to talk about this issue and the feelings and thoughts associated with it." participants in the poor listening condition read the following scenario: "imagine that you are talking about the negative bias that you mentioned on the previous page with a person who has a neutral attitude (neither positive nor negative) towards this group. during the conversation, you feel that your conversation partner is not trying to understand your views or experiences relating to your negative bias and is judgmental about the things you are saying. his reactions, questions, and comments show you that he does not take any interest in you and your experiences -in what you have to say about the bias. during the conversation, your conversation partner does not convey any empathy; he is not attuned to your feelings behind the negative bias and does not show he understands how difficult it is to talk about this issue and the feelings and thoughts that are associated with it." in the regular listening condition, participants read the following scenario: "imagine that you are talking about the negative bias that you mentioned on the previous page with a person who has a neutral (neither positive nor negative) attitude towards this group. during the conversation, you talk about several different features of your bias. you did not feel it was an eventful conversation one way or another. overall you felt it was an ordinary conversation." finally, participants responded to measures of perceived listening as a manipulation check, self-insight, and perceived attitude change were debriefed and compensated. all measures were anchored on a 7-point likert type scale (1 = 'not at all'; 4 = 'moderately'; 7 = 'very much') as described in the pilot study materials (see supplementary materials). listening perception (manipulation check). speakers' listening perception was assessed on the 10-item layperson-based listening scale (α = 0.98; lipetz et al., 2018) . an example item is: "to which extent did you feel that your conversation partner showed interest in what you had to say?" self-insight. a five-item scale that included the following items: "how much do you feel this conversation: "helped to understand yourself better?", "made you think more deeply about the topic?" "helped you to discover new or different insights about yourself?" "helped you to reflect about your attitudes?" and "helped you think about things in a different way?" (α = 0.92). openness to change. openness to change with regard to the prejudiced attitude was adapted from previous research (omoto & snyder, 1995) . specifically, it read: "to which extent do you feel that the conversation changed your attitude about the bias?" reflective self-awareness was used as an additional assessment for self-insight. six items from trapnell and campbell (1999) were adapted to the present setting (α = 0.80). example items were (translated from hebrew): "during the conversation, i explored my inner-self", "during the conversation i analyzed my bias", and "i don't feel that this conversation prompted me to introspect about my bias" (reverse coded). table 1 presents the descriptive statistics and the correlations between variables. listening perception (manipulation check). an analysis of variance (anova) indicated a main effect of the listening manipulation on perception of high quality listening, f(2,382) = 442.37, p < .001, ŋ 2 p = 0.70, cohen's f = 1.52. post-hoc lsd tests indicated that these effects differed across all the experimental conditions. specifically, in line with the nature of the manipulations, participants in the high quality listening condition (m = 5.82, sd = 0.98) perceived higher quality listening than participants in the neutral (m = 4.51, sd = 1.15), m difference = 1.32 se = 0.14, p < .001, 95%ci [1.05, 1.58], and poor listening conditions (m = 1.99, sd = 1.06), m difference = 3.84, se = 0.13, p < .001, 95%ci [3.58, 4.10]. in addition, participants in the regular listening condition perceived higher quality listening more than participants in the poor listening condition, m difference = 2.52 se = 0.13, p < .001, 95%ci [2.26, 2.78]. self-insight. an anova indicated a main effect of the listening manipulation on self-insight, f(2,382) = 120.63, p < .001, ŋ 2 p = 0.39, cohen's f = 0.80. post-hoc lsd tests indicated a significant difference where participants in the high quality listening condition (m = 4.93, sd = 1.19) reported higher self-insight than participants in the regular listening condition (m = 4.24, sd = 1.35), m difference = 0.69 se = 0.17, p < .001, 95%ci [0.36, 1.02], and participants in the poor reflective self-awareness. complementing findings for the measure of self-insight, a significant main effect of the listening manipulation on reflective self-awareness was found, f(2,382) = 33.17, we conducted a mediation analysis using model 4 in process (hayes, 2017) using 5000 bootstrapped samples (preacher & hayes, 2008) to test hypothesis 3, that self-insight would relate to openness to change and mediate the effect of the listening manipulation. we did not assume linearity between the listening conditions; therefore, we created two dummy variables. the variable dummy 1 compared the high quality listening condition (coded as "1") to the neutral and poor listening conditions (coded as "0"). the variable dummy 2 compared the poor listening condition (coded as "1") to the supportive and regular listening condition (coded as "0"). we tested mediation for each of the two variables that represented self-insight, controlling for the other dummy code. 3 first, we tested the mediation model with high quality vs. regular and poor quality listening (dummy 1) controlling for dummy 2 (poor listening vs. high and regular quality listening). the indirect effect through self-insight was significant, b = 0.46, se = 0.12, 95%ci [0.24, 0.69], meaning that the high versus regular quality listening condition predicted self-insight, and self-insight, in turn, related to openness to change as hypothesized. the direct effect was not significant, b = 0.03, se = 0.18, t = 0.15, p = .88, 95%ci [−0.33, 0.38], indicating that relative to regular listening, good listening did not have an effect on openness to change when controlling for its effects through self-insight (see fig. 2a ). similar results were obtained with reflective self-awareness as a mediator; namely, the indirect effect was significant, b = 0.18, se = 0.07, 95%ci [0.05, 0.33], and the direct effect was not significant, b = 0.31, se = 0.20, t = 1.56, p = .12, 95%ci [−0.08, 070] (see fig. 2a and c) . in sum, regardless of which measure was used to test selfinsight, this construct appeared to be an underlying factor in explaining the effects of high quality listening on openness to change. the mediation analysis with poor quality listening versus regular and high quality listening (dummy 2) as the independent variable provided additional support for the hypothesized model. the indirect effect from dummy 2 to openness to change through self-insight, when controlling for dummy 1, was significant, b = −1.16, se = 0.14, fig. 2b and d), suggesting that self-insight provides a good account of the effects of listening on attitudes. in conclusion, these additional mediation analyses further support the hypothesized model. thus poor listening showed effects in line with those of high quality listening: its impact on openness to change is better understood through its more immediate effects on self-insight. these findings provided confirmatory evidence for hypotheses 1 and 2 regarding the main effects of listening on self-insight and openness to change. the results of study 1 indicated that both high quality listening and independently, poor listening, contribute to self-insight and attitudes as compared to regular listening. this experiment also validated our measure of self-insight and showed that effects were robust for both measures across all main and meditational effects. specifically, the results indicated that self-insight mediated the effect of high quality listening conditions on openness to change in relation to one's prejudiced attitudes. however, this study had two important shortcomings. first, although scenario experiments are often used to measure interpersonal listening (e.g., , and are a recommended approach to experimental manipulations (aguinis & bradley, 2014) , they only provided a proxy for an actual interaction. in addition, the way that people imagine they would feel and behave in uncomfortable situations such as when witnessing discrimination may differ from how they actually behave in these situations (kawakami et al., 2009 ). thus, this experiment was limited with regard to its ecological validity, and it remains unclear whether the effects would be replicated in an actual interpersonal encounter. in addition, hypothesis 3, regarding the effect of high quality listening on prejudice, was not tested in the present experiment. the first goal of study 2 was to increase ecological validity by using an actual conversation partner. second, we tested whether the listening-induced self-reported attitude change would correspond to lower prejudice. while attitude exploration and change is a crucial aspect of many prejudice reduction efforts (paluck & green, 2009) , it is possible, though unlikely, and that change can shift towards greater prejudice. to rule out this possibility, we added a widely validated measure of prejudice (correll et al., 2010) , the feeling thermometer, to complement the measure of attitude change. c. study 1: a mediation analysis of dummy 1 controlling for dummy 2 on attitude change via reflective self-awareness; standard errors in parentheses; ⁎ p < .05, ⁎⁎ p < .01. d. study 1: a mediation analysis of dummy 2 controlling for dummy 1 on openness to change via reflective self-awareness; standard errors in parentheses; ⁎ p < .05, ⁎⁎ p < .01. feel bias towards any groups of people"). hence, the final sample size was 127 individuals (m age = 19.30, sd = 1.33, 89.8% female). power analysis using gpower indicated that this sample size has a power of above 0.80 to detect the average effect size on attitude change that was obtained in the pilot study and study 1 (cohen's d = 0.51). sensitivity analysis showed that the weakest effect size that such a sample could detect with a power of 0.80 was d = 0.44. participants entered the laboratory and were seated at a cubicle, which provided privacy from the researcher. the researcher explained that the study consisted of three parts: responding to an online questionnaire, a brief conversation, and responding to another questionnaire afterward. the first questionnaire contained a consent form, demographics, and the following instructions to write about an incident that evoked prejudice: "i would like you to take a couple of minutes to think about a specific bias that you may feel or may have felt. most people will have felt some sort of bias during their lives. this bias can be towards any group of people, for example, older people, people of color, the opposite gender, or people from different socioeconomic status. in the box below, please write about this bias, how you were feeling, and what your overall experience was." afterward, participants turned their chairs around to face the researcher. the researcher started the conversation with the following preface: "i would now like you to describe the bias you just wrote about to me. everything we talk about here is confidential and will not be recorded. when you are ready, please begin". the ra allowed the participants to talk for as long as they wanted. once it was clear that the participant had finished talking, she said: "thank you for sharing this with me today, when you are ready, there are a few questionnaires for you to fill out on the computer." in the regular listening condition (n = 64), the researcher merely listened without responding; however, researcher responses included head nodding and minor communications of acknowledgment (hmmm, i see) to maintain naturalness and avoid actively alienating the participants. participants in the high quality listening condition (n = 63) were given the same instructions as participants in the regular listening condition. in the conversation, the researcher responded by nodding and saying specific phrases when prompted. these phrases included questions about the bias and the participant's experience and empathic responses such as "i realize this can be difficult to talk about." although the researcher minimized the number of responses to allow sufficient time for listening to occur, responses were directly designed to communicate interest in what the speaker was saying, along with empathy and non-judgment (unconditional regard). once it was clear that the participant had finished talking, the researcher instructed them to complete the second part of the questionnaire. at the end of the experiment, the participants were debriefed, thanked, and given credit for their participation. listening perception (manipulation check). we used the same measure as in study 1. the items were anchored on a 7-point likerttype scale (1 = 'not at all'; 7 = 'very much'; α = 0.97). the measure was the same as the one used in study 1. items were anchored on a likert-type scale (1 = 'not at all'; 5 = 'very much'; α = 0.88). openness to change. we used the same item as in study 1, which was anchored on a likert-type scale (1 = 'not at all'; 5 = 'very much'). attitude favorability towards the prejudiced group. prejudiced attitudes were measured with a feeling thermometer, which ranged from 0° (very cold or unfavorable feelings) to 100° (very warm or extremely favorable feelings) with regard to the group they talked about during the conversation. this thermometer is frequently used to examine a variety of prejudiced attitudes (e.g., correll et al., 2010; haddock & zanna, 1997 haddock et al., 1993) . higher scores indicate less prejudice. table 2 presents the descriptive statistics and the correlations between variables. to examine how listening shapes attitudes through the facilitation of introspection, we conducted a serial-mediation analysis using model 6 in process (hayes, 2017 ). specifically, we tested the effect of the listening manipulation on attitude favorability towards the prejudiced group via increasing self-insight openness to change. we anticipated that as individuals perceived more change in their prejudicial attitudes, they would also report more favorable (less prejudiced) attitudes towards the outgroup they described. note that although the main effect of the high quality listening manipulation on self-reported attitude change was not significant, mediation can still occur (rucker et al., 2011) . as can be seen from fig. 3 , the indirect effect from the listening manipulation to attitude favorability through self-insight and openness to change was significant, b = 3.38, se = 1.43, 95%ci [0.88, 6.46]. thus, the mediation analysis provided support for hypothesis 3, namely, that high quality listening will reduce speakers' prejudiced attitudes towards the outgroup by increasing self-insight and openness to change. however, the direct effect was significant, b = 11.03, indirect effects conceptually replicated study 1, but results for direct effects did not. the final analysis also supported the downstream consequences of openness to change. it meaningfully related to more favorable attitudes towards the outgroup, reinforcing the view that perceptions of change reflected actual attitudes and demonstrated that perceived change was not in the counterproductive direction (i.e., increased negative attitudes). study 2 largely provided support for h3 and increased the ecological validity of the study by using a live interaction. specifically, the listening manipulation was effective with regard to reducing speakers' prejudiced attitudes. in addition, speakers who experienced high quality listening were able to delve deeper into their biases (i.e., increased self-insight), which in turn resulted in less prejudice or more favorable attitudes towards the group. in addition, the results of the pilot study and study 1, which recruited participants from israel, were replicated with participants from great britain. the generalization of findings across two cultures speaks to the robustness of the models across samples, which most likely came from different demographic backgrounds and held different biases (bond & gudykunst, 1997) . however, despite its merits, the approach used in study 2, which let participants select any group they wished to discuss as a target of their prejudice, may have resulted in participants selecting socially acceptable groups to discuss. as a result, we cannot be certain that any of the beneficial effects of listening translated into lower prejudice towards any specific outgroups. this is a problem when attempting to generalize effects to real-life conversations, where typically there are specific groups under discussion. in addition, from an attitude strength perspective (krosnick & petty, 1995) , the participants might have chosen relatively weak attitudes (i.e., ambivalent; demarree et al., 2011) so that the conversation would be more comfortable or less threatening. previous work had found that people's attitudes are more likely to respond to change inductions when their initial attitude was weak (i.e., ambivalent; demarree et al., 2011). we conducted study 3 to address these issues. the primary objective of study 3 was to provide a conceptual preregistered replication of study 2, once again using an in-person interaction that manipulated listening quality (https://aspredicted.org/ blind.php?x=ej27v9). second, we tested the effect of high quality listening on stronger prejudiced attitudes relative to the previous studies and used a more robust measure of prejudiced attitudes, namely, change in attitude favorability from before to after the conversation. we also modified the procedure in two ways to account for the possibility that participants would select to discuss weak or socially acceptable attitudes. first, rather than permitting participants to select any group of their choosing, we asked participants to discuss one of five groups that experience the most prejudice in israel: those who are black, homeless, immigrants to israel, gay, and transgender. of these, they were asked to discuss the group towards which they reported the least favorable attitudes at the start. in addition, we measured participants' perceived social acceptance of the outgroup attitude directly and tested whether it would moderate the listening manipulation on attitude favorability towards the outgroup. social acceptance is a basic and motivating need in interpersonal interactions, including those that concern prejudice (kunstman et al., 2013) . in the context of the present research, the desire for social acceptance may influence the content of the discussion such that speakers only describe attitudes they perceive is normative and thus acceptable to express in front of the listener. to explore this, we examined this possible boundary condition to the effects of high quality listening: namely, that the effects of high quality listening on speakers' prejudice depends on the extent that the speaker feels that the expressed attitude is socially acceptable. undergraduate students from israel (n = 245) 5 participated in this study in exchange for course credit. as specified in the preregistration form, we excluded nine participants who did not report their bias towards a group as instructed. examples are: "i am gay, out of the closet. i have friends in the community who are transgender, and i see the discrimination towards them, they are treated disrespectfully and are perceived as unusual from the community,"; and "in the past i used to be afraid of homeless people. however, today as i have matured, i now offer them a hot meal and something to drink." the final sample size was n = 236 (m age = 26.55, sd = 6.77, 68.2% female). this sample size had a power of above 0.80 to detect the average effect size on attitude favorability that was obtained in study 2 (cohen's d = 0.42). sensitivity analysis using gpower (faul et al., 2007) showed that the weakest effect size that this sample could detect with a power of 0.80 was d = 0.37. four research assistants (ras; three females, one male; m age = 24.25, sd = 7.89) participated in the study as listeners. they received listening training and followed a protocol that was written for the present study. every ra performed both the good and regular listening conditions in a randomized order. the experiment included two stages. first, participants signed a consent form and completed a questionnaire where they indicated, using the thermometer, their attitude towards five social groups, namely those who are black, homeless, immigrants, gay, and transgender. of the five groups, 28.4% selected fig. 3 . study 2: serial-mediation analysis of the effect of listening on attitude favorability towards prejudiced groups via self-insight and openness to change; standard errors in parentheses; ⁎ p < .05, ⁎⁎ p < .01. 5 as stated in preregistration form, we aimed for n = 328 to have a power of 95% to detect the hypothesized effect. however, because of the outbreak of covid-19, in-lab experiments were no longer permitted as of march 2020. therefore we had to stop data collection. g. itzchakov, et al. journal of experimental social psychology 91 (2020) 104022 homeless individuals, 27.5% selected immigrants to israel, 19.1% chose transgender individuals, 12.7% selected black people, and 12.3% selected gay individuals as the group they held the least favorable attitudes. afterward, the participants indicated to what extent they thought that it is socially acceptable to have a negative attitude towards each specific group. subsequently, participants were asked to select the group towards which they had the most negative attitude and write a short description or give an example of their bias. in the second stage, participants were informed that they would talk about the attitude towards the group they wrote about with the person in the lab (i.e., the ra). as in study 2, participants were randomly assigned to the high quality (n = 115) or the regular listening condition (n = 121). the behavior of the listeners in both conditions was the same as described in study 2. only a single listener-speaker dyad was present in each experimental session to eliminate potential artifacts related to social influence and distraction. after the conversation, participants answered questionnaires that included the outcome variables and were debriefed by the ras. none of the participants guessed the goals or nature of the study. the most frequent answers regarding the objective of the study were that it was meant to characterize students' attitudes towards minority groups, build knowledge about prejudice in the israeli society, and examine conversations between people who do not know each other. the likert-type scales ranged from 1 ('not at all') to 9 ('very much'). we followed best practice recommendations and used a scale with a wider range of anchors to increase validity and capture more variability (aguinis et al., 2009) . listening perception 1. in order to increase the construct validity of the manipulation check, we used the constructive behavior sub-scale from the facilitating listening scale (kluger & bouskila-yam, 2018) . previous work has found that this scale has strong correlations with other validated listening measures (itzchakov et al., 2014) . this measure is composed of 10 items, α = 0.95. example items were: "when my conversation partner listened to me, he or she (a) tried hard to understand what i was saying, (b) listened to me attentively, and (c) asked questions that showed his/her understanding of my opinions." listening perception 2. as another measure of the listening manipulation, participants responded to the following item: "to what extent would you like to experience the kind of listening you experienced in the conversation again?". participants dragged the slider from 0° (not at all) to 100° (very much). self-insight. the measure was the same as the one used in studies 1 and 2, α = 0.87. openness to change. we used the same item as in the previous studies. cognitive reappraisal. a new measure of cognitive reappraisal was used here (jones & wirtz, 2006) . this measure served as an additional indicator of openness to change and was composed of four items: namely: (a) "my conversational partner made me think about the attitude i described during the conversation", (b) "i feel that i ought to re-evaluate the event now, after the conversation", (c) "i don't really see the conversation in a different light after the conversation" (reversecoded), and (d) "i understand the situation better now that i talked about it with my conversation partner", α = 0.70. attitude favorability change towards the outgroup. attitude favorability towards the prejudiced group was measured twice: before and after the listening manipulation. hence, the dependent variable was the change in attitude favorability. as in study 2, prejudiced attitudes were measured with a feeling thermometer that asked about participants' attitudes towards the group they talked about during the conversation. the measure ranged from 0° (very cold or unfavorable feelings) to 100° (very warm or extremely favorable feelings) with regard to the group they talked about during the conversation. attitude favorability change (or prejudice reduction) was computed as attitude favorability (post-conversation) -attitude favorability (pre-conversation). the correlation between the participants' pre-listening attitude favorability and post-listening attitude favorability with regard to the group they chose was r = 0.74, p < .001. perceived social acceptance of prejudice. participants indicated the extent they perceived that it was socially acceptable to express a negative attitude towards each of the five groups using a feeling thermometer measure. the slider ranged from 0 ('not at all acceptable') to (table 3) . table 3 presents the descriptive statistics and the correlations between the variables. listening perception 1. participants in the high quality listening condition reported experiencing better listening (m = 8.38, sd = 0.91) than participants in the regular listening condition (m = 6.31, sd = 2.19), t(234) = 9.38, p < .001, 95%ci [1.63, 2.50], d = 1.22. listening perception 2. participants reported a greater desire to reexperience the type of listening in the high listening condition (m = 89.38, sd = 13.64) than participants in the regular listening condition (m = 62.03, sd = 36.27), t(234) = 7.72, p < .001, 95%ci [20.82, 34 .78], d = 1.01. thus, overall, the manipulation was successful. self-insight. participants in the high quality listening condition had higher levels of self-insight (m = 5.97, sd = 1.69) than participants in the regular listening condition (m = 4.30, sd = 2.27), t(234) = 6.40, p < .001, 95%ci [1.16, 2.18], d = 0.83. openness to change. participants in the high quality listening condition (m = 3.36, sd = 2.50) reported higher openness to change notes. experimental condition was coded: 1 = regular listening, 2 = high quality listening; ⁎ p < .05 ⁎⁎ p < .01. higher scores on attitude favorability change correspond to higher prejudice reduction; reliabilities in parentheses; a-refers to the outgroup that the participant selected. g. itzchakov, et al. journal of experimental social psychology 91 (2020) attitude favorability change towards outgroup. we conducted analyses of covariance (ancova) with the experimental condition as a predictor of the post-listening prejudice score while controlling for the pre-listening scores on prejudice. consistent with our prediction, the ancova indicated a significant main effect of condition, f (1,233) = 4.92, p = .028, η 2 p = 0.02. specifically, participants in the high quality listening condition (m adjusted = 45.95, se = 1.65) reported a more favorable attitude towards the outgroup than participants in the regular listening condition, (m adjusted = 40.84, se = 1.61). 6 however, the confidence interval for prejudice change within the high quality listening condition crossed 0: 95% ci [−1.06, 5.70] (regular listening condition was: 95% ci [−6.80, 0.78]). therefore, the high quality listening condition only led to increased attitude favorability towards the outgroup relative to a similar conversation taking place in the context of regular listening. we conducted two serial-mediation analyses using model 6 in process (hayes, 2017) . as indicated in the preregistration, we tested two mediation models, specifically, (a) a mediation of the listening manipulation on attitude favorability change via self-insight and openness to change, and (b) a mediation of the listening manipulation on attitude favorability change via self-insight and reappraisal. as can be seen from fig. 4a , the indirect effect from the listening manipulation to attitude favorability change through self-insight and openness to change was significant, b = 1.41, se = 0.67, 95%ci [0.07, 2.71], suggesting high-quality listening promoted openness to change through its effects on self-insight. the direct effect was not significant, b = 4.45, se = 2.77, t = 1.60, p = .111, 9.90] , suggesting self-insight explained substantial variance in the conditionopenness to change effect. the reverse indirect effect from the listening manipulation to attitude favorability change via openness to change and introspection was not significant, b = −0.002, se = 0.22, 95%ci [−0.46, 0.47] . a similar pattern was observed with reappraisal as the second mediator. as can be seen in fig. 4b , the indirect effect from the listening manipulation to attitude favorability change via self-insight and cognitive reappraisal was significant, b = 2.00, se = 0.95, 95%ci [0.20, 3.92] . the direct effect was not significant, b = 3.05, se = 2.77, t = 1.10, p = .271, 95%ci [−1.00, 9.90 ]. the reverse indirect effect from the listening manipulation to attitude favorability change via cognitive reappraisal and introspection was not significant, b = −0.29, se = 0.70, 95%ci [−1.63, 1.15]. we examined whether the perception of social acceptance of the prejudiced attitude moderated the effect of the listening manipulation on the change in attitude favorability. the results of model 1 in process (hayes, 2017) indicated that the perceived social acceptance was not a significant moderator, b = −0.10, se = 0.09, t = −1.20, p = .231, 95%ci [−0.27, 0.07]. r 2 change = 0.006, f(1,232) = 1.45, p = .231. this result hints that perceived social acceptance does not serve as an alternative explanation for the effect of high quality listening on reducing speakers' prejudiced attitudes. fig. 4 . a. study 3: serial-mediation analysis of the effect of listening on attitude favorability change towards prejudiced groups via self-insight and openness to change; standard errors in parentheses; ⁎ p < .05, ⁎⁎ p < .01. b. study 3: serial-mediation analysis of the effect of listening on attitude favorability change towards prejudiced groups via self-insight and cognitive reappraisal; standard errors in parentheses; ⁎ p < .05, ⁎⁎ p < .01. in sum, the results of study 3 generally supported the research hypotheses. the present study conceptually replicated study 2 and addressed several of its limitations with four methodological and analytic advances. first, the effect of high quality listening on the dependent variables was replicated using a more conservative procedure, namely, following discussions of attitudes towards one of a small number of pre-specified outgroups. second, the main effect of the listening manipulation on cognitive reappraisal alongside the significant indirect effect identifying cognitive appraisal as a mediator increased the validity of the model. third, the use of a change score for attitude favorability provided a more precise measure of prejudice reduction that was directly due to the listening manipulation. finally, though somewhat underpowered, the lack of moderation effect between the listening quality manipulation and perceived social acceptance predicting attitude favorability change increases the confidence that the benefits of high quality listening found in studies 2 and 3 were unrelated to perceived social acceptance. we conducted a random-effects meta-analysis on the pilot study and studies 1-3 (n = 952, including the pilot study). in study 3, we included the two listening manipulation checks. in study 2, we converted the cohen's f score to a cohen's d and used the measure of reflective selfawareness as an additional indicator of self-exploration. in study 3, we used the measure of cognitive reappraisal as an additional indicator of openness to change. as can be seen in table 4 , the average effect size of the listening manipulation check across the three experiments was very strong, d = 2.11, as was the average effect on self-insight, d = 1.17, ps < .001. neither of these effects showed evidence of heterogeneity (although the τ for the manipulation check was large, and may not be significant due to low power). the average effect size of openness to change was d = 0.46, p < .001, with no evidence of heterogeneity across the experiments. despite the non-significant main effect of listening on attitude change in study 2 (d = 0.25, p = .169), this mini meta-analysis suggests that high quality listening, as compared to regular and poor listening, increased openness to change meaningfully across the three experiments and the pilot study. finally, the average effect size of the listening manipulation on attitude favorability was d = 0.32, p = .002, with no evidence of heterogeneity. experimental studies showed that as compared to poor listening (study 1) and regular listening (all studies), high quality listening when discussing prejudiced attitudes facilitated speakers' self-insight, and through doing so promoted more positive attitudes. to the best of our knowledge, these studies constitute the first empirical attempt to test how listening shapes discussions of prejudice and explores a promising explanation of why attitudes shifted, namely, higher self-insight. in the present studies, complementary experimental designs allowed for a largely causal interpretation of the downstream consequences of high quality as compared to regular and poor quality listening. these findings inform theoretical claims related to the self-integrative process by suggesting that when conversations occur in the presence of a supportive listener, the climate facilitates reflection and self-insight about one's experiences (rogers, 1951 (rogers, , 1980 . often, during the process of reflection, people can reconcile contradictory or ambivalent attitudes. acknowledging this ambivalence and the complexity of attitudes is what rogers predicted would result from experiencing high quality listening, and is consistent with the empirically supported therapeutic approach of motivational interviewing that his work inspired. specifically, high quality listening elicits different and sometimes contradictory views within the speaker, that they must reconcile. this process often leads to behavioral or attitudinal changes in the speaker (miller & rose, 2009) . previous work outside of the therapeutic context has shown that high quality listening by a layperson (not a trained clinician) can also have an impact on speakers' attitudes (e.g., , though these studies focused on ambivalent attitudes, more generally. the present results provided mixed support for the view that listening can affect attitudes: we did not find compelling evidence that the experience of being listened to reduced prejudice from baseline (tested in study 3); however, we did find, consistently, that high quality listening led to lower prejudice than regular or poor listening did when speakers talked about their attitudes. these findings highlight that high quality listening is beneficial when individuals are asked to discuss their prejudiced attitudes. in other words, conversations about such attitudes are best had in the context of listening that conveys empathy, understanding, and support. however, these findings should be understood in the context of their boundary conditions. first, it is plausible that speakers in our studies selected to discuss moderate, rather than extreme, prejudiced attitudes. we cannot be certain that conversations about extreme attitudes would be benefited by the quality of listening similarly to our observed effects. second, since we elicited self-reflection for the purposes of the study, it is possible that participants had not previously reflected on the attitudes they discussed. in cases where people have previously reflected on their beliefs but continue to express prejudice, high-quality listening might not show the robust benefits over regular listening identified here, as there is little or no ambivalence in beliefs to resolve. more generally, it is important to understand boundary conditions before applying any prejudice reduction strategy. as another example, we did not find evidence that a conversation about prejudice with someone who provides high quality listening is the solution to longstanding, pervasive problems of prejudice in societies, but we did observe that it benefited an individual's attitudes in the short-term and when compared to a similar conversation with a regular quality listener. further work examining the long-term impacts of high-quality listening on both self-insight and attitudes is critical to understand how interventions with listening can be formalized. it is important to contextualize the present findings within the larger literature on prejudice reduction strategies. while high quality listening constitutes a new strategy in the context of prejudiced attitude change, it aligns with and complements prior work. for example, value consistency is a complementary approach to the one we used here, where participants consider the extent to which their prejudice is inconsistent with other values they hold (e.g., equality). value consistency has been shown to be effective (e.g., eisenstadt et al., 2003) , and may help explain our finding that self-insight predicted lower prejudice; namely, self-insight may allow participants to realize and accept that prejudiced attitudes are inconsistent with other values they hold. further, the effect of high quality listening studied here was not driven by intergroup contact, which is arguably the most effective of all prejudice-reduction strategies (pettigrew & tropp, 2006) , because participants did not interact with a member of the outgroup in any of the studies. it seems plausible, however, that experiencing high quality listening when it is provided by an outgroup member could produce even stronger effects on prejudice reduction. finally, some research has indicated that perspective-taking is an effective prejudice reduction strategy (broockman & kalla, 2016; shih et al., 2009) , where participants take the perspective of the outgroup. by contrast, the studies here involved participants' experience of feeling heard when they expressed their perspective. it seems plausible that conversations that facilitate the perspective-taking of both parties could be even more effective in reducing prejudice. future research should test the effectiveness of combining high quality listening with these other documented strategies in the prejudice-reduction literature (e.g., mutual perspective sharing and taking, high quality listening provided by an outgroup member). these findings further inform the literature on therapeutic interventions and conversations aimed towards attitude change beyond the context of prejudice reduction. although we focused on prejudiced attitude change in this study, the processes hypothesized here are relevant to difficult conversations dealing with sensitive or potentially defense-inducing topics more broadly, including but not limited to attitude change (e.g., conflicts in romantic relationships). though there is a substantial emphasis on incorporating high quality listening into therapeutic interventions with couples at present (chessick, 1989; graybar & leonard, 2005) , it is helpful for researchers and practitioners alike to understand the mechanisms that are involved in linking high quality listening to its beneficial effects, as well as the limits of these effects across domains, subjects, relationships, and clients. although the present studies merely scratch the surface of these research questions, they provide a launchpad for further explorations on the extent to which high quality listening facilitates the kinds of behavior and attitude change that therapists and other conversation partners hope to see. the present research has further implications for other healthcare contexts where self-insight is important. a good example is medical and hospital visits. doctors interrupt their patients, on average, 12 s after their patients start talking (rhodes et al., 2001) . hence, not surprisingly, one of the patients' main complaints is that their doctors do not listen to them (boudreau et al., 2008) . interestingly, the lack of selfinsight might explain why patients who report that their doctors do not listen to them are less likely to adhere to their recommendations (magnus et al., 2013) . it is further worth noting that in study 1, poor listening actively undermined self-insight. arguably, poor listening reduces the willingness to change attitudes because it elicits defensiveness, which then discourages any positive integration tendencies like self-insight or openness to change. this finding sheds further light on the listening literature, which shows that speakers also suffer from poor listening. these include reducing the quality of speakers' narration and speech fluency (bavelas et al., 2000) , as well as impairing speakers' memory (pasupathi et al., 1998) , psychological safety , and their creativity (castro et al., 2018) . it is possible that poor listening reduces available cognitive resources, in part, because it puts speakers in a defensive stance, and that poor listening may backfire and increase prejudice among speakers. this backfiring effect has indeed been demonstrated in contexts low in autonomy support, where people are told that they must change without being able to express themselves or have their perspective understood (legault et al., 2011) . studies 2 and 3 did not employ poor listening because our primary interests were the beneficial effects of listening on attitudes, but future research could examine the detrimental effects of poor listening, particularly on prejudice. these findings should be viewed in light of several limitations. first, attitudes were measured through self-reports. future research should complement them with measures of implicit bias and behavioral indicators of prejudice. as such, the present findings may have been vulnerable to social desirability effects (e.g., janus, 2010) . implicit measures and behavioral observations of prejudice would help to validate measures of self-reported attitudinal change. in a similar vein, we focused our mediational analyses on explanations focused on fairly complex internal processes resulting from being listened to (e.g., selfinsight), but the effects of listening on attitudes may be better, and more simply, explained by other proximal of listening, such as interpersonal comfort (williams & irurita, 2004) , psychological safety (carmeli & gittell, 2009; castro et al., 2016; itzchakov et al., 2016) , or even the valence of mood. indeed, it is reasonable to assume that being listened to improves mood, which has downstream effects on attitudes (haddock et al., 1994) . although good listening perception increased openness to change relative to regular listening and poor listening, the average rating on this measure was below the midpoint of the scale, even following the listening intervention, indicating the difficulty of nurturing openness. future work should contrast listening with other interpersonal constructs, including those that have been found to increase open-mindedness in the context of attitude change (itzchakov & reis, 2020) . third, we manipulated several aspects of high quality listening simultaneously, but future work should consider manipulating specific qualities (e.g., careful attention, demonstrations of empathy, unconditional regard) in isolation to examine each of their separate contributions to listening effects on attitudes. at present, we can only assume that each of these contributed to the self-insight and non-prejudiced attitudes reported by our participants, but future work is needed to examine this assumption. finally, future research should complement this work with observed and coded data from naturalistic conversations such as those that take place between therapists and clients. future work could also manipulate high quality listening in the context of a prejudice reduction program such as unconscious bias training, which focuses on information dissemination to reduce prejudice (noon, 2018) . this form of training could be enhanced by having trainers use high quality listening strategies with attendees in helping them to explore their biases. testing this possibility is important because most research on unconscious bias training programs have reported weak effects at best (lai et al., 2016) , and many workplaces are highly invested in the goal of reducing prejudice in their organization. the present research used experimental paradigms to manipulate listening and examined its consequences on speakers' self-insight and prejudiced attitude change. the findings highlight the importance of high quality listening for productive conversations and the potential detriments of poor listening. they suggest that in therapeutic practice, and presumably in other, informal, daily conversations, listening partners can help facilitate self-insight to 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educational model for cultivating engagement across differences supplementary data to this article can be found online at https:// doi.org/10.1016/j.jesp.2020.104022. key: cord-326971-jekqhslx authors: schnepper, rebekka; reichenberger, julia; blechert, jens title: being my own companion in times of social isolation – a 14-day mobile self-compassion intervention improves stress levels and eating behavior date: 2020-10-09 journal: front psychol doi: 10.3389/fpsyg.2020.595806 sha: doc_id: 326971 cord_uid: jekqhslx the worldwide spread of the coronavirus disease (covid-19) and the resulting lockdown has affected the whole world and the maintenance of healthy eating behavior might be an additional challenge. self-compassion (sc) interventions emphasize not only treating oneself in a caring way regarding personal weaknesses, e.g., diet lapses, but also the recognition of shared human suffering. thus, self-compassion might be particularly valuable during the current worldwide crisis due to covid-19. in this study, n = 65 participants that wanted to lose weight or develop a healthier eating behavior were randomized to either a 14-day self-compassion intervention arm or a waitlist control arm. the intervention consisted of daily journaling exercises and meditations via smartphone with a focus on improving eating behavior. before and after the intervention phase, questionnaires on self-compassion, eating, dieting, health behavior, stress, and emotion regulation were completed and body weight was determined. participants in the treatment arm (n = 28) showed an increase in self-compassion, a decrease in perceived stress, eating in response to feeling anxious, and, on trend level, body mass index (bmi). changes in self-compassion fully mediated changes in stress. no such effects were found in the waitlist control group (n = 29). thus, self-compassion might help to maintain well-being and healthy eating habits in times of increased stress and isolation. future studies should replicate these findings outside of the covid-19 crisis and test the effect of self-compassion in samples with eating disorders or weight problems. at the beginning of 2020, governments all over the world passed laws to curb the spread of the coronavirus disease , caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2). this new virus is highly contagious and became a global pandemic within weeks. groups at risk for a severe course are older people or people with preexisting chronic diseases like diabetes or autoimmune disorders. however, also in healthy adults, fatal cases with respiratory or cardiac failure as a frequent cause of death occurred (beeching et al., 2020) . due to the restrictions that lasted at least 2 months in most of the countries, public life halted -educational institutions, restaurants/bars/cafés, cultural and sports facilities, and non-essential shops were closed, events were canceled, and gatherings with people from different households were forbidden. during the peak of daily infections and deaths, more than half of the world population was on some sort of lockdown (sandford, 2020) . the pandemic confronted people with various fears: contracting covid-19 themselves (fitzpatrick et al., 2020) , job loss due to economic recession, and having to postpone long-term plans, like a change in occupation, place of residence, or getting a degree in time. further, social isolation during lockdown can result in loneliness, a worsening of pre-existing mental illnesses, and in increased anxiety and depression in populations that experience additional strain, e.g., health care workers and parents (holmes et al., 2020) . a review that investigated the psychological impact of being in quarantine identified a longer duration, fear of getting infected, frustration, boredom, inadequate basic and medical supplies, inadequate information on the current situation, financial loss, and stigma when being quarantined due to exposure to the virus as stressors (brooks et al., 2020) . in a swiss general population study, half of the participants reported an increase in stress, and 57% of the participants had an increase in depression scores and in anxiety levels (de quervain et al., 2020) . in a spanish sample, especially women, people with a history of mental illness, and people experiencing symptoms of covid-19 themselves or in close relatives reported a worsening of mental health (gonzález-sanguino et al., 2020) . thus, it is important to provide practical advice, support, and coping strategies for managing boredom, loneliness, and stress (brooks et al., 2020) . isolation and quarantine might also affect health behavior like physical activity or eating negatively. to illustrate, restrictions during the lockdown period made it more difficult to remain physically active (pinto et al., 2020) , which again can have a negative impact on mental health (lippi et al., 2020) . further, stress (adam and epel, 2007) , negative emotions (konttinen et al., 2010) , and boredom (havermans et al., 2015) can cause an increase in food cravings and a preference for high-calorie "comfort food. " besides, loneliness and social isolation have been related to the occurrence of binge eating (mason et al., 2016) and the risk of developing an eating disorder (levine, 2012) . indeed, there is initial evidence that the covid-19 lockdown had a negative impact on eating behavior. in an international survey, participants reported unhealthier eating habits, which might be partly due to a higher availability of unhealthy food as a consequence of stockpiling to avoid potential shortages of food (ammar et al., 2020) . in an italian sample, half of the participants reported eating more during lockdown, especially comfort food, and 19.5% reported weight gain. participants attributed this to an increase in anxiety, boredom, and stress (scarmozzino and visioli, 2020) . thus, measures might be needed that promote healthy eating directly and also support coping with its predecessors like stress and isolation to prevent negative consequences of restrictions due to covid-19 (lippi et al., 2020) . in this context, self-compassion (sc) might play an important role, especially for vulnerable populations that were already concerned about their diet or weight prior to the lockdown. self-compassion is a concept that recently attracted a lot of interest. it can be defined by having a kind, non-judgmental attitude towards the own self, especially regarding perceived weaknesses (neff, 2003b) . through sc, reflecting on these weaknesses is not avoided, but rather dealt with in a compassionate, gentle attitude and the aim to identify and fulfill own personal needs -similarly how one would treat a good friend in such a situation (neff, 2003b) . according to neff (2003b) , self-compassion entails three interrelated components: first, self-kindness, i.e., being gentle toward oneself in the face of failure and inadequacies (vs. self-judgment due to frustration with these shortcomings), second, common humanity, i.e., recognizing that everyone experiences suffering (vs. self-isolation, i.e., getting absorbed in an egocentric perspective on one's own problems). third, non-judgmental mindfulness/present moment awareness (vs. over-identification with negative feelings). studies show that higher sc is associated with less worrying (keng et al., 2012) , as well less anxiety and depression symptoms (van dam et al., 2011) . in addition, sc correlates with more adaptive coping in response to negative emotions and negative events . thus, sc might aid in protecting against the abovementioned negative consequences of social isolation due to the covid-19 lockdown. with regard to eating behavior and body weight, sc has shown potential to improve factors that are not addressed by traditional diets, including body image and disordered eating (rahimi-ardabili et al., 2018) . it also helps to reduce unhealthy eating styles, including restrictive eating and binge eating (pinto-gouveia et al., 2019) , which are risk factors for the later development of an eating disorder. further, it might facilitate mindful eating by making individuals more receptive for mindfulness interventions (mantzios and wilson, 2015) . self-kindness instead of self-isolation has been identified as possible pathways how self-compassion can prevent binge eating (webb and forman, 2013) . these abilities might be especially helpful in times of increased distress and isolation during the covid-19 pandemic. although a review showed beneficial effects of sc on eating behavior, body image, and weight loss (rahimi-ardabili et al., 2018) , previous studies suffered from several limitations like failing to include a control group (pinto-gouveia et al., 2019) , combining sc with other helpful components like mindfulness, yoga, and psychoeducation, or only assessing short-term effects. furthermore, no study has yet explored sc interventions in the context of a global crisis as the current one, despite their high applicability to fundamental and existential threats. in this study, participant who wanted to lose weight or change their eating behavior received a 2-week, smartphonebased self-compassion intervention. effects were compared to a waitlist control group. we hypothesized that first; selfcompassion would increase in the intervention group (ig) compared to baseline, while no change would be evident in the waitlist group (wg). second, we expected a positive effect of the intervention on stress experience related to covid-19 restrictions. third, we hypothesized that the intervention would help participants to improve their eating behavior and reduce their body mass index (bmi). for the second and third hypothesis, we explored whether changes in self-compassion mediate possible changes in stress, eating behavior, and bmi and if this relation was different between the two groups. we aimed for a sample size of 80 participants (40 participants per condition), based on a power (1-ß) of 0.80, α = 0.05, and a medium effect size of f = 0.25 in a repeated measures anova with within-between interaction, two groups, and two time points. this estimation took a possible dropout rate of 15% into account. however, since the duration of the lockdown phase was unclear and the intervention lasted 14 days, we further took into consideration how many participants could be tested in a short period of time when calculating the sample size. data collection was stopped when signs pointed toward the lockdown measures being eased. the final sample consisted of n = 57 participants who were recruited via newspaper articles, social media, and university newsletters between march and may 2020 when lockdown restrictions were stepwise increased in austria and germany. 1 after expressing interest, they first filled out an online questionnaire to determine whether they met inclusion and did not meet exclusion criteria. inclusion criteria were being fluent in german, experiencing impairment in daily life due to the covid-19 lockdown (i.e., not going to work as usual), and the goal to lose weight or to develop a healthier eating behavior. exclusion criteria were a lifetime eating disorder and a current pregnancy or breastfeeding. all participants received an individual feedback based on their data; psychology students additionally had the possibility to receive five study credits (26.3% of the final sample). in the final sample, 64.9% of the participants were students, 22.8% were employees, and 12.3% had other occupations. the most frequent main reason for participating was the wish to lose weight (40%), followed by wanting to eat healthier (39%), wanting to have more regular meals (12%), and wanting to improve their emotional eating patterns (9%). see table 1 for further sample characteristics. participants that met inclusion criteria received an informed consent form with the instruction to sign it and send it back via e-mail. further, they received a link to the baseline questionnaire, which included demographic information as well 1 due to the unpredictability of the lockdown duration, we did not define a precise sample size, but aimed to include at least n = 40 participants per condition. our final sample is slightly below this aim, but comparable to other studies that applied a self-compassion training pinto-gouveia et al., 2019) . as questionnaires on self-compassion, eating, dieting, health behavior, stress, emotion regulation, and a virtual food rating task. after completing the baseline questionnaire, participants were randomly allocated to the ig or wg, using a randomization scheme created with the website randomizer.org. then, they received login information for the app psydiary and installation instructions via a telephone call. the app was used during the 14-day intervention to provide the self-compassion exercises for the ig. further, both groups answered end-of-the-day questions on self-compassion, mindfulness, mood, eating behavior, and experienced consequences of the lockdown (results reported elsewhere). daily notifications reminded participants to do the self-compassion exercise and to answer the questionnaire. afterward, participants completed a post questionnaire similar to baseline. upon completion, the wg received the intervention. the ethics committee of the university of salzburg, austria approved of the study. see figure 1 for a flowchart of the study. 2 the 2-week sc intervention that aimed to increase sc was mostly inspired by material provided by dr. kristin neff (2020). it consisted of three different meditations and eight different journaling exercises in alternating order. both journaling exercises and meditations have been found to increase self-compassion and thereby assist in weight loss (mantzios and wilson, 2014) . exercises were adapted to the theme of improving one's eating behavior. in this context, participants learned to be mindful and less critical about negative emotions, but rather see them as a part of being human. when starting the intervention, participants were instructed to follow the structure of the 2-week plan that indicated which exercise should be done on each day. they were also encouraged to start a sc journal and to continue doing the exercises over the course of multiple weeks. the journaling exercises covered different, related topics: writing a letter about a perceived weakness regarding eating behavior to oneself from the perspective of a loving friend, reflecting on how participants would treat a friend in a similar situation, exploring the participants' self-criticism when trying to improve their eating behavior, and finding alternative and less critical ways to motivate themselves. further, they learned how to treat themselves kindly when experiencing food cravings, to recognize that unhealthy eating is not self-compassionate, and to find alternatives to reward themselves. the meditations contained compassionate breathing exercises, sc affirmations and soothing touch. each meditation repeated in the 2nd week, while each journaling exercise was only done once. the german 26-item version (hupfeld and ruffieux, 2011) of the original scale (neff, 2003a) consists of six subscales that assess three positive components of sc as well as three negative counterparts: self-kindness (as opposed to self-judgment), common humanity (as opposed to isolation), and mindfulness (as opposed to over-identification). in previous studies, subscales were highly intercorrelated and best explained by an underlying construct of general self-compassion (neff, 2003a; hupfeld and ruffieux, 2011) . participants indicate how they typically act toward themselves in difficult times from 1 = "almost never" to 5 = "almost always. " an example item for self-kindness is "i'm kind to myself when i'm experiencing suffering, " an example for common humanity is "when i feel inadequate in some way, i try to remind myself that feelings of inadequacy are shared by most people, " and an example for mindfulness is "when i'm feeling down i try to approach my feelings with curiosity and openness. " after reverse coding negative items, a sum score for sc can be calculated. internal consistencies in the present study were cronbach's α = 0.910 for self-kindness, α = 0.769 for common humanity, α = 0.706 for mindfulness, α = 0.726 for self-judgment, α = 0.765 for isolation, α = 0.606 for over-identification, and α = 0.919 for the overall scale at baseline and cronbach's α = 0.859 for self-kindness, α = 0.864 for common humanity, α = 0.729 for mindfulness, α = 0.855 for self-judgment, α = 0.744 for isolation, α = 0.640 for over-identification, and α = 0.927 for the overall scale after the intervention phase (hupfeld and ruffieux, 2011) . the german version (klein et al., 2016) of the perceived stress scale (pss; cohen et al., 1983) investigates the experience of psychological stress in the past month. it consists of 10 items (e.g., "in the last month, how often have you been upset because of something that happened unexpectedly?") which are answered on a scale from 1 = "never" to 5 = "very often. " in this sample, stress levels were considerably higher than in previous general population samples (cohen et al., 1983; klein et al., 2016) . internal consistencies in the present study were cronbach's α = 0.834 at baseline and cronbach's α = 0.861 after the intervention phase (klein et al., 2016) . the salzburg emotional eating scale (sees; meule et al., 2018) assesses changes in eating behavior in response to four emotional figure 1 | phases of the study design and number of participants who completed each phase. participants that met eligibility criteria were invited to fill out the baseline questionnaire. frontiers in psychology | www.frontiersin.org states (happiness eating, sadness eating, anger eating, and anxiety eating). it consists of 20 items (e.g., "when i am worried, …"), which are rated from 1 = "i eat much less than usual" to 5 = "i eat much more than usual. " in this study, we included an overall scale of eating in response to negative emotions (i.e., sadness, anger, and anxiety), and each negative subscale separately. internal consistencies in the present study were cronbach's α = 0.826 for sadness eating, α = 0.845 for anger eating, α = 0.853 for anxiety eating, and α = 0.878 for overall emotional eating at baseline and cronbach's α = 0.854 for sadness eating, α = 0.857 for anger eating, α = 0.813 for anxiety eating, and α = 0.887 for overall emotional eating after the intervention phase (meule et al., 2018) . at baseline and post measurement, participants were asked to upload a photo of a scale showing the participants body weight. 3 this information was then used to analyze changes in bmi. using spss 26 (ibm, 2019), independent t-tests were conducted to test for baseline differences between wg and ig. further, 2 × 2 (group × time) mixed anovas were computed to test the pre-specified hypotheses on changes in outcome variables between pre and post measurement, and whether the intervention would interact with this change. eta squared was calculated as an estimate for effect sizes, with η 2 > 0.01 indicative of a small effect, η 2 > 0.06 of a medium effect, and η 2 > 0.11 of a large effect. for further analyzing the intervention effect on the other outcome variables, an sc change score was computed and grand mean centered. the process 3.5 macro for spss (hayes, 2013) was used to build a mediation model with groups as a predictor for change scores of stress, bmi, and eating behavior, and the sc change score as a mediator. on average, participants in the ig reported that they completed an sc exercise on 11.5 of the 14 days (sd = 2.27). the exercises were estimated to be moderately helpful (m = 55.1 on a continuous scale from 0 to 100), with no difference between meditations and journaling exercises, p = 0.125. with specific regard to the current lockdown situation, the exercises were somewhat helpful (m = 43.3 on a continuous scale from 0 to 100). here, participants reported meditations to be more useful, p = 0.019. the overall sc score showed a main effect of time, f(1,55) = 7.26, p = 0.009, η 2 = 0.117, that was moderated by 3 n = 5 in the ig and n = 6 in the wg did not own a scale and were not able to determine their weight due to the lockdown. figure 2 for group differences in sc. a group × time interaction, f(1,55) = 5.70, p = 0.020, η 2 = 0.094 pointed to different time courses in the two groups. figure 3a indicates that perceived stress decreased in the ig while it increased in the wg. analyzing changes in bmi for the 81% of participants who were able to provide a photo of their body weight showed a trend group × time interaction, f(1,44) = 3.81, p = 0.057, η 2 = 0.080. post hoc tests showed a significant group difference at post measurement, f(1,47) = 4.58, p = 0.038, η 2 = 0.089. figure 3d shows that while bmi decreased in the ig, it increased in the wg. analyzing analyzing changes in bmi for the 81% of participants who were able to provide a photo of their body weight showed a trend group × time interaction, f(1,44) = 3.81, p = 0.057, η 2 = 0.080. post hoc tests showed a significant group difference at post measurement, f(1,47) = 4.58, p = 0.038, η 2 = 0.089. figure 3d shows that while bmi decreased in the ig, it increased in the wg. in this study, we applied a mobile 2-week sc intervention to individuals that wanted to reduce their weight or improve their eating behavior during the covid-19 lockdown. intervention effects were compared to a waitlist control group, which only answered daily questionnaires without completing an exercise. as expected, the ig showed increases in sc, which was especially visible in an increase in self-kindness and a decrease in self-isolation. in the context of the lockdown, experiencing less isolation might be particularly beneficial for mental well-being (liu et al., 2020) . further, perceived stress during lockdown decreased in the ig. this is in line with recent studies that showed the positive effect of a mindfulness intervention on anxiety and sleep quality during the covid-19 lockdown (zheng et al., 2020) . mediation analyses showed that a reduction in stress was due to increases in sc in the ig, showing that training sc can be a helpful tool to acquire stress coping skills. this is remarkable because reported stress in this sample was almost as high as in a sample of patients treated for work-related stress and mood disorders (glasscock et al., 2018) , which shows the detrimental effect that the lockdown policies had on mental health. the intervention also had a positive effect on emotional eating: the ig reported less eating in response to negative emotions, especially in response to anxiety. as the lockdown and uncertainties related to the spread of the virus has the potential to increase anxieties, which has been shown to negatively impact eating behavior (scarmozzino and visioli, 2020) , sc can pose a protective factor against the establishment of unhealthy eating habits. further, bmi trend effects are in line with the previously reported protective role of sc against binge eating disorder (pinto-gouveia et al., 2019) . however, a lack of significant results might also indicate a conflicting figure 2 | group changes in overall self-compassion and for the subscales self-kindness and isolation before and after the 14-day intervention. frontiers in psychology | www.frontiersin.org effect of self-compassion: when feeling psychologically unwell, physiological long-term health might not be prioritized. consequently, self-kindness might lead to self-indulgence and an unhealthy but comforting snack might be permitted (mantzios and egan, 2017; egan and mantzios, 2018) . if future studies with a higher power show similar, more robust effects, this would be especially valuable as studies show the potential weight gain during the lockdown (e.g., di renzo et al., 2020) . unfortunately, not all participants were able to track weight changes since they did not own a scale, and due to the lockdown could not go elsewhere to weigh themselves. while other studies found a direct positive effect of sc components on eating behavior (webb and forman, 2013) , mediation analysis showed no direct effect of sc on emotional eating or weight. considering the increase in stress levels during the lockdown period (de quervain et al., 2020) , which were reported to be a cause for unhealthy eating behavior (scarmozzino and visioli, 2020) , the decrease in perceived stress might have helped to eat more balanced and less in response to negative emotions. again, a larger sample might help to clarify these effects that were significant on a trend level. besides the rather small group size, it has to be noted that although compliance to do an sc exercise each day was very high, the perceived helpfulness of the sc exercises can be improved. more guidance during the intervention phase, personalization of the training plan, and individualized diet or weight goals during the intervention period might help to increase the effect of the intervention. a long-term follow-up might help to determine the temporal stability of effects. in the waitlist group, participants filled out daily questionnaires on sc, eating behavior, mindfulness, and mood, which were needed for comparing ema data in the two groups. however, this could have drawn the participants' attention to these topics, thus creating an attenuated intervention effect. lastly, we did not preregister our hypotheses due to the limited amount of time in the lockdown situation. future studies are planned to overcome these shortcomings and replicate findings. despite these limitations, this study has various strengths. following recommendations of rahimi-ardabili et al. (2018), we tested the effect of an sc intervention and compared it to a waitlist control group, thus acquiring longitudinal and causal effects instead of mere correlational data. effect sizes were either medium or large, highlighting the potential of our intervention. further, we were able to apply the sc intervention in a highly stressful and potentially threatening time that affected everyone to some degree. previous studies showed the risk for weight gain especially in vulnerable populations like individuals with obesity (almandoz et al., 2020) . although the present study did not explicitly target overweight or obese individuals, we focused on individuals with an interest in weight loss who might face similar challenges during the lockdown. as face-to-face meetings were hardly possible during the covid-19 lockdown, the benefit that participants drew from the intervention is of high value. research calls for e-mental health technologies to provide necessary interventions during the covid-19 lockdown (wind et al., 2020) . the use of a mobile smartphone app and the intervention and installation instruction via phone further made the intervention feasible as well as cost and time saving during the lockdown situation. in the future, it might also be used as an add-on to existing therapies. in conclusion, the present study provides promising data on the positive effect of sc interventions, which should be transferred to regular daily life after the lockdown and to other vulnerable groups, e.g., individuals with obesity or an eating disorder. the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. the studies involving human participants were reviewed and approved by ethics committee of the university of salzburg, austria. the patients/participants provided their written informed consent to participate in this study. rs designed and conducted the study, did the statistical analyses, and drafted the manuscript. jr helped with the design of the study and contributed to the final draft. jb helped with the design of the study, acquired funding, and contributed to the final draft. all authors contributed to the article and approved the submitted version. stress, eating and the reward system promoting self-compassionate attitudes toward eating among restrictive and guilty eaters impact of covid-19 stay-at-home orders on weight-related behaviors among patients with obesity effects of covid-19 home confinement on eating behaviour and physical activity: results of the eclb-covid19 international online survey coronavirus disease 2019 (covid-19). available at the psychological impact of quarantine and how to reduce it: rapid review of the evidence a global measure of perceived stress the swiss corona stress study eating habits and lifestyle changes during covid-19 lockdown: an italian survey a qualitative exploration of self-kindness and "treating oneself " in contexts of eating, weight 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impact of covid-19 outbreak information on sleep duration key: cord-035447-xjv64wp2 authors: mcdonald, mollie a.; meckes, samantha j.; lancaster, cynthia l. title: compassion for oneself and others protects the mental health of first responders date: 2020-11-13 journal: mindfulness (n y) doi: 10.1007/s12671-020-01527-y sha: doc_id: 35447 cord_uid: xjv64wp2 objectives: first responders are at elevated risk for psychological distress from frequent exposure to potentially traumatic events. self-compassion may buffer against the negative impact of these stressors, and the potential emotional challenges of having high levels of compassion for others. however, little is known about the psychological impact of compassion in first responders. we examined how self-compassion, compassionate love for others, and service role interacted to predict mental health in a diverse group of first responders. methods: first responders (n = 171) with both traditional and emotional support roles completed an online survey including measures of self-compassion, compassionate love, psychological distress, post-traumatic stress, secondary traumatic stress, burnout, resilience, compassion satisfaction, and life satisfaction. results: greater self-compassion and compassionate love both independently predicted less depersonalization (|β|s ≥ .18, ps < .01). greater self-compassion predicted less general psychological distress, post-traumatic stress, secondary traumatic stress, and emotional exhaustion, as well as greater resilience and life satisfaction (|β|s ≥ .35, ps < .001). greater compassionate love predicted greater personal accomplishment and compassion satisfaction for all first responders (|β|s ≥ .30, ps < .001); for traditional first responders only, greater self-compassion predicted greater personal accomplishment and compassion satisfaction (role x self-compassion; |β|s ≥ .16, ps < .05). emotional support first responders reported less emotional exhaustion and greater resilience than traditional first responders (|β|s ≥ .21, ps < .05). conclusions: self-compassion and compassionate love each play important roles in promoting mental health among first responders. programs designed to increase compassion could be beneficial in this population. supplementary information: the online version contains supplementary material available at 10.1007/s12671-020-01527-y. helping professions (raab 2014) . three published studies have examined self-compassion in first responders specifically. self-compassion buffered against the influence of selfcriticism on depression in firefighters (kaurin et al. 2018) , and self-acceptance (a statistically derived factor composed of self-compassion items) predicted resilience among paramedics and dispatchers (bilsker et al. 2019) . additionally, fire service personnel who participated in a compassion-focused intervention experienced greater increases in self-compassion, but not greater mental health gains, compared to active controls (beaumont et al. 2016c ). although two of these studies suggest that self-compassion could be a promising protective factor for first responders, more research is needed to replicate these results and test if they generalize to other first responders and symptoms. relative to self-compassion, there is little research on the psychological impact of compassion for others. furthermore, this body of research has been less consistent in the operationalizations and scales used to measure compassion for others and closely related constructs. in its most basic form, compassion for others is defined as a feeling of concern and a desire to help when exposed to others' suffering, but several operationalizations exist (see strauss et al. 2016 for review) . similar to the aforementioned definition of self-compassion, some researchers have defined compassion for others according to buddhist principles (hereafter referred to as mindful othercompassion), making these measures broader than the basic definition, as they incorporate additional components (e.g., mindful awareness; pommier 2011; pommier et al. 2019 ). other researchers have focused more specifically on altruism, conceptualizing compassion as compassionate love, which is defined as an enduring trait that encompasses empathic feelings as well as patterns of behavior (e.g., self-sacrificing tendencies) toward different groups of people (hwang et al. 2008; sprecher and fehr 2005) . an even narrower focus has been applied by researchers examining empathy, a construct encompassing the affective (e.g., empathic concern) and cognitive (e.g., perspective taking) components of experiencing concern for others' suffering, but not including the desire to help or helping behavior (davis 1983) . researchers have highlighted the importance of distinguishing between compassion and empathy and how they might differentially predict mental health outcomes (sinclair et al. 2017) , especially because sharing negative emotions alone can have negative psychological consequences if those emotions go unregulated (macdonald and price 2019). however, the basic definition of compassion encompasses empathy, and quantitative results have supported this overlap, such that mindful other-compassion and compassionate love were correlated with empathy in previous research (hwang et al. 2008; pommier et al. 2019) . compassion for others is a particularly important construct to study among first responders, because those who join helping professions may do so because they are especially motivated to help others (ben-shem and avi-itzhak 1991) . given first responders' role in predominately helping strangers, we chose to operationalize compassion for others using a stranger-focused measure of compassionate love (hwang et al. 2008) . this measure uses the basic definition of compassion but more specifically focuses on feelings of concern and prosocial behaviors toward strangers, which may be particularly important for first responders. however, due to the dearth of literature on the psychological impact of compassion for others, we broadened our literature review to include studies that operationalized compassion for others in a variety of ways. despite previously observed correlations between other-compassion constructs (hwang et al. 2008; pommier et al. 2019) , it is important to take into consideration that different measures may contribute to the mixed findings present in this body of literature. among the relatively few studies that have been conducted examining other-compassion constructs, findings have varied widely. some research has suggested that compassion for others is unrelated to mental health. for example, compassionate love was not related to depression, anxiety, or stress in a sample of undergraduates (catarino et al. 2014) , nor was it associated with depression or ptsd symptoms in a sample of veterans (kearney et al. 2013) . in a sample of police officers, empathy was not associated with secondary traumatic stress . however, other studies have suggested that compassion for others is protective. for example, compassionate love was shown to predict better mental health, such as greater positive affect, self-esteem, and life satisfaction, as well as lower levels of negative affect and anxiety, in undergraduates (chiesi et al. 2020) . compassionate love also marginally predicted less depression in caregivers of individuals with alzheimer's disease (monin et al. 2015) . empathy was associated with happiness and life satisfaction in undergraduates, and happiness and positive affect in a community sample (wei et al. 2011) . in helping professionals, greater mindful other-compassion predicted beneficial psychological outcomes, including lower secondary traumatic stress and burnout as well as greater compassion satisfaction and wellbeing (beaumont et al. 2016a, b) . additionally, aspects of empathy (e.g., empathic concern) were shown to predict greater compassion satisfaction and lower secondary traumatic stress and burnout among helping professionals (duarte and pinto-gouveia 2017; duarte et al. 2016; richardson et al. 2016; wagaman et al. 2015; yi et al. 2019) . furthermore, greater compassionate love was shown to predict greater professional commitment and lower burnout in nurses (mersin et al. 2020) . therefore, compassion for others and related constructs could be useful predictors of first responders' professional and personal quality of life. on the other hand, some studies suggest that too much compassion for others could potentially have harmful effects. in the general population, aspects of empathy were associated with greater stress (birnie et al. 2010) . according to reviews examining predictors of secondary traumatic stress, findings were mixed, but suggested that empathy was not protective, such that empathy had either no relationship or a positive relationship with secondary traumatic stress (sinclair et al. 2017; . in a sample of mental health professionals, greater mindful other-compassion was associated with greater secondary traumatic stress (mantelou and karakasidou 2019) . among health professionals, aspects of empathy (e.g., empathic concern, personal distress) were associated with greater secondary traumatic stress and burnout and less compassion satisfaction, although negative (e.g. secondary traumatic stress) and positive (e.g., compassion satisfaction) outcomes sometimes occurred simultaneously (duarte and pinto-gouveia 2017; duarte et al. 2016; hunt et al. 2019) . finally, among police officers, empathy predicted greater burnout . it is important to assess the role that other-compassion constructs have in first responders' lives, beyond the one existent published study , because secondary traumatic stress and burnout could result in harmful consequences for first responders and their communities (swider and zimmerman 2010) . preliminary research suggests that the mixed findings surrounding compassion for others might be explained in part by a moderating effect of self-compassion. specifically, the beneficial correlates of self-compassion could buffer against the potentially harmful correlates of empathic concern. in a sample of nurses, greater empathic concern was related to greater secondary traumatic stress, but only for those with lower aspects of self-compassion (e.g., self-kindness; duarte et al. 2016 ). however, further research is necessary to determine if this pattern of findings, suggesting the protective influence of self-compassion among those with high levels of empathic concern, extends to first responders and additional measures of compassion for others. in general, almost nothing is known about the impact of compassion for others on mental health in first responders. this is surprising, given the vast body of research showing the protective effects of self-compassion, and the emerging (although mixed) research on the effects of other-compassion constructs. much of this prior research was done with helping professionals (e.g., nurses). although the frequency of indirect exposure to traumatic events makes this group similar to first responders, traditional first responders (e.g., police officers, firefighters) experience high levels of direct threats to personal safety (reichard and jackson 2010) . because of these differences in duties between first responders and other helping professionals, we expect that psychological outcomes related to compassion could be different for these groups. given the mixed findings in previous research, we decided to base our predictions upon findings from the one study that evaluated the interaction between aspects of self-compassion and an overlapping other-compassion construct in a sample of helping professionals (duarte et al. 2016) . specifically, in this study, greater empathic concern predicted greater secondary traumatic stress (referred to as compassion fatigue in the study) among nurses with low self-kindness. therefore, we predicted that greater compassionate love would predict greater secondary traumatic stress, but only among first responders with low self-compassion. we expected to see similar patterns of results for related mental health outcomes, such as general psychological distress, post-traumatic stress, and burnout. we also explored the possibility that self-compassion would interact with compassionate love when predicting positive mental health outcomes, such as resilience, compassion satisfaction, and life satisfaction. in the absence of an interaction between self-compassion and compassionate love, we expected that greater self-compassion would predict better overall mental health (consistent with meta-analytic results; macbeth and gumley 2012; zessin et al. 2015) . however, in the absence of an interaction between self-and other-compassion, we were uncertain what the main effect of other-compassion (i.e., compassionate love) might be, given the mixed findings of prior studies. thus, we took an exploratory approach and did not determine an a priori hypothesis for the main effect of compassionate love. additionally, in our study, we had the opportunity to sample traditional first responders (e.g., police officers, firefighters) and first responders participating in a program specifically designed to provide emotional support onscene to people in crisis (e.g., after the sudden death of a family member). therefore, we explored the possibility that emotional support first responders might differ from traditional first responders in the role that compassion plays in maintaining their mental health. to allow for the possibility that traditional first responders differ from first responders specializing in emotional support, we examined the interaction of first responder role with self-compassion and compassionate love. the current sample was composed of adult volunteer and professional first responders. in total, 240 participants completed at least a portion of the survey, and 219 (91%) were eligible for participation (e.g., age 18+, were first responders, had experience responding to one or more emergency calls). eligibility was also determined during the second wave of data collection (spring 2019) by excluding participants (n = 4) who indicated that they had completed a similar survey during the time frame of the first wave of data collection (spring 2018). listwise deletion was used to derive a sample of participants who had completed all of the measures used in the current study, resulting in a sample of 171 (71%). according to an a priori power analysis, we needed a sample size of n = 139 to obtain 80% power to detect a medium effect size (f 2 = .15) when testing a multiple regression model with 15 predictors. thus, we obtained sufficient power to detect a clinically meaningful impact on psychological outcomes, despite the high number of predictors in our models. of the subset of participants used for the current study (n = 171), the majority were male (73%), white or caucasian (92%), not hispanic or latino (92%), 40 years of age and older (53%), in a relationship (80%), employed full-time (89%) with an annual income greater than $100,000 (64%), and had an education level of less than a bachelor's degree (52%). law enforcement (39%) was the most commonly endorsed first responder affiliation. organizational affiliation was used to determine service role, such that participants affiliated with the trauma intervention program were coded as emotional support first responders due to their role of proving on-scene crisis support (n = 31), and all other affiliations were coded as traditional first responders (n = 140). (see table 1 for additional demographic information.) participants were recruited in the western united states through mass emails sent out by organization leaders in police and fire departments, as well as the trauma intervention program. electronic informed consent was obtained from all subjects. data were collected via qualtrics march 2018-may 2019. participants completed a larger assessment battery (see supplemental table 1 for descriptive statistics); data from relevant variables were analyzed for the current study. those who completed the full survey were compensated with a $20 electronic gift card. all procedures were approved by the university of nevada, reno, institutional review board. demographics participants reported several demographic characteristics, including organizational affiliation, gender, race, ethnicity, age range, educational level, etc. (see table 1 for additional demographic information). demographic characteristics were compared across service role groups (traditional versus emotional support first responders), and any demographic characteristics that significantly differed between groups were included in subsequent analyses to attempt to control for these differences (see table 1 for information about group comparisons). scale -form c (mc-sds-c) is a 13-item measure designed to account for socially desirable response style with comparable psychometrics to the long form (reynolds 1982 ). we controlled for social desirability because previous research identified a correlation between social desirability and compassionate love (sprecher and fehr 2005) . the internal consistency of the mc-sds-c in the current study was acceptable (α = .71). a sum score was generated on a 0-13 scale, with higher scores indicating a greater tendency to be concerned with social approval. stress exposure two measures were used to assess exposure to stressful events. participants reported an estimated number of calls or emergencies that they responded to in the previous month, which was used as a proxy for frequency of recent exposure to stress. participants also responded to the life events checklist for dsm-5 (lec-5), a 17-item measure of lifetime exposure to different types of potentially traumatic events (weathers et al. 2013) . although psychometric data is not currently available for the version updated for dsm-5, the previous version was shown to have reasonable psychometric properties, and only minor changes were made to the measure (gray et al. 2004) . for each item, we coded any form of exposure to a potentially traumatic event as one, and no exposure as zero. a summed score was calculated (range 0-17) as a measure of variety in lifetime history of trauma exposure. similar scoring methods for trauma exposure have been used in previous research (brownlow et al. 2018 ). self-compassion the self-compassion scale -short form (scs-sf) is a 12-item measure of one's tendency to be selfcompassionate that retains the strong psychometric properties of the longer form (neff 2003; neff 2020b; raes et al. 2011) . the internal consistency of the overall scs-sf score in the current study was good (α = .83). a total mean score was generated on a 1-5 scale, with higher scores indicating more frequent self-compassion. questions were recently raised concerning whether a total self-compassion score should be used to assess self-compassion as a protective factor (muris and otgaar 2020; neff 2020a) . critics of the total score suggested that reverse-coded negatively worded items, which are more reflective of self-criticism rather than self-compassion, may be driving results indicating that self-compassion is protective against psychopathology (muris and otgaar 2020) . for this reason, we conducted post hoc analyses to examine if our pattern of results was maintained when using only the positively worded or negatively worded items (see supplementary materials). compassionate love the santa clara brief compassion scale (scbcs) is a psychometrically sound 5-item measure of one's tendency to be compassionate toward others, particularly strangers (hwang et al. 2008; plante and mejia 2016) . for the sake of clarity, we refer to this construct as compassionate love (the name given by the original scale developers; sprecher and fehr 2005) to clearly distinguish it from other measures of compassion for others and related constructs. the scbcs has been criticized for using the word "compassion" the percentage points for the organization variable sum to greater than 100% because roughly 10% of all participants belonged to more than one organization, as indicated by the "multiple organizations" category **p < .01. ***p < .001 in its items, relying on participants' potentially differing individual definitions of compassion when responding (strauss et al. 2016) . additionally, the definition of compassion underlying the scbcs does not align with the definition used in our measure for self-compassion, which limits our ability to compare the influence of compassion across constructs (strauss et al. 2016 ). however, the scbcs's focus on compassion and altruism toward strangers makes it a suitable measure to use with first responders. furthermore, according to previous research, the scbcs demonstrated good psychometric properties such as internal reliability, split-half reliability, test/retest reliability, convergent validity, and divergent validity (plante and mejia 2016) . the internal consistency of the scbcs in the current study was excellent (α = .90). a mean score was generated on a 1-7 scale, with higher scores indicating more compassionate love for others. the 21-item depression, anxiety, and stress scale (dass-21) was used as a measure of general psychological distress within the last week (lovibond and lovibond 1995) . the dass-21 is a reliable and valid measure with three subscales: depression, anxiety, and stress (osman et al. 2012 ). however, an overall score of emotional symptoms can be used (beaufort et al. 2017 ). the observed internal consistency was excellent (α = .93). in line with scoring instructions, a z-score based on a normative sample was generated, with higher scores indicating greater symptom severity (lovibond and lovibond 1995) . the ptsd checklist for dsm-5 (pcl-5) is a 20-item measure of ptsd symptoms over the past month with good psychometrics (blevins et al. 2015) . the observed internal consistency of the pcl-5 was excellent (α = .93). a sum score was generated on a 0-80 scale, with higher scores indicating greater symptom severity. . the stss is a 17-item measure of secondary traumatic stress symptoms within the last week. it has good psychometric properties (bride et al. 2004) , and the observed internal consistency was excellent (α = .94). a sum score was generated on a 17-85 scale, with higher scores indicating more frequent symptoms. burnout an abbreviated, 9-item version of the maslach burnout inventory (ambi) was used to assess the frequency of burnout symptoms experienced within the context of being a first responder (mcmanus et al. 2000) . the ambi is a reliable measure (riley et al. 2018) , composed of three subscales, with most demonstrating good internal consistency in the current sample: personal accomplishment (α = .64; a lower cronbach's alpha than was observed in previous research; riley et al. 2018) , depersonalization (α = .86), and emotional exhaustion (α = .83). a sum score on a 0-18 scale was generated for each subscale, with higher scores indicating a more frequent experience of the given construct. resilience the brief resilience scale (brs) is a reliable and valid 6-item measure of one's tendency to bounce back after a stressor (smith et al. 2008 ). the observed internal consistency was good (α = .86). a mean score on a 1-5 scale was generated, with higher scores indicating greater resilience. the compassion satisfaction subscale of the proqol-5 (stamm 2010) is a 10-item measure that is both reliable and valid, despite psychometric concerns about other proqol-5 subscales (hemsworth et al. 2018) . the internal consistency of the compassion satisfaction subscale in the current study was excellent (α = .92). a sum score on a 10-50 scale was generated for this subscale, with higher scores indicating a more frequent experience of compassion satisfaction over the past 30 days. life satisfaction the satisfaction with life scale (swls; diener et al. 1985 ) is a reliable and valid 5-item measure of life satisfaction (pavot and diener 2008) . the internal consistency of the swls in the current study was good (α = .90). a sum score was generated on a 5-25 scale, with higher scores indicating greater life satisfaction. statistical analyses were conducted with r v.3.6.2 (r core team 2019). descriptive statistics were calculated for all variables (see supplemental table 2 ), and pearson correlations were calculated for all pairs of continuous variables (see supplemental table 3 ). multiple regression analyses were used to examine whether self-compassion and compassionate love explain a significant portion of the variance in the aforementioned psychological symptoms across two groups of first responders while controlling for social desirability, stress exposure, and any demographic variable that predicted differences between service roles. we began with a full model that included our control variables (social desirability, recent stress exposure, diversity of lifetime stress exposure, age range (0 = 18-25; 1 = 30-39; 2 = 40-49; 3 = 50+), relationship status (0 = in a relationship; 1 = not in a relationship), gender (0 = male; 1 = female), annual income range (0 = less than $100,000; 1 = greater than $100,000), and employment status (0 = full-time; 1 = not full-time)), as well as the main effects and interactions relevant to the primary research questions (service role (0 = traditional; 1 = emotional support), self-compassion, compassionate love, self-compassion x service role, compassionate love x service role, self-compassion x compassionate love, and self-compassion x compassionate love x service role). we used backwards elimination to remove non-significant interaction terms. backwards elimination was completed by first removing the three-way interaction term if it was non-significant, then removing the two-way interaction term with the highest p value at each step until all interaction terms included in the model were significant. this allowed us to more accurately estimate lower-order interaction terms or main effects when higher-order interactions were non-significant. continuous variables were standardized. assumptions were checked for all final models. variance inflation factors (vif) indicated that multicollinearity was not an issue (vifs ≤ 2.23; suggested cutoff, vif < 10; marquardt 1970) . (see table 2 for final models.) predictors in the final model explained 33% of the variance in psychological distress (f(11, 159) = 7.19, rmse = .85, p < .001). self-compassion was the only significant predictor of interest, with greater self-compassion predicting lower levels of psychological distress (β = − .51, se(β) = .07, p < .001), after accounting for the influence of other variables (demographics, stress exposure, social desirability, service role, and compassionate love). predictors in the final model explained 33% of the variance in ptsd symptoms (f(11, 159) = 7.12, rmse = .85, p < .001). self-compassion was the only significant predictor of interest, with greater self-compassion predicting lower levels of ptsd symptoms (β = − .49, se(β) = .07, p < .001), after accounting for the influence of other variables (demographics, stress exposure, social desirability, service role, and compassionate love). predictors in the final model explained 26% of the variance in secondary traumatic stress symptoms (f(11, 159) = 4.95, rmse = .89, p < .001). self-compassion was the only significant predictor of interest, with greater self-compassion predicting lower levels of secondary traumatic stress (β = − .38, se(β) = .07, p < .001), after accounting for the influence of other variables (demographics, stress exposure, social desirability, service role, and compassionate love). personal accomplishment predictors in the final model explained 12% of the variance in feelings of personal accomplishment (f(12, 158) = 4.19, rmse = .90, p < .001). greater compassionate love was associated with greater personal accomplishment (β = .31, se(β) = .08, p < .001), after accounting for the influence of other variables (demographics, stress exposure, social desirability, service role, and self-compassion). additionally, we observed a significant two-way interaction between self-compassion and service role (β = − .18, se(β) = .20, p = .040), such that greater self-compassion was a predictor of greater personal accomplishment in traditional first responders (β = .21, se(β) = .08, p = .013), but not in emotional support first responders (β = − .20, se(β) = .18, p = .259), after accounting for the influence of other variables (demographics, stress exposure, social desirability, and compassionate love). due to the subscale's low observed internal consistency, these results should be interpreted with caution. depersonalization predictors in the final model explained 53% of the variance in depersonalization (f(11, 159) = 16.51, rmse = .71, p < .001). greater self-compassion (β = − .18, se(β) = .06, p = .002) and greater compassionate love (β = -.32, se(β) = .06, p < .001) were independently associated with less depersonalization, after accounting for the influence of other variables (demographics, stress exposure, social desirability, and service role). emotional exhaustion predictors in the final model explained 43% of the variance in emotional exhaustion (f(11, 159) = 10.74, rmse = .78, p < .001). greater self-compassion (β = − .35, se(β) = .06, p < .001) was associated with less emotional exhaustion, and emotional support first responders experienced less emotional exhaustion than traditional first responders (β = − .26, se(β) = .23, p = .004), after accounting for the influence of other variables (demographics, stress exposure, social desirability, and compassionate love). predictors in the final model explained 31% of the variance in resilience (f(11, 159) = 6.49, rmse = .86, p < .001). greater self-compassion (β = .46, se(β) = .07, p < .001) was associated with greater resilience, and emotional support first responders endorsed higher levels of resilience than traditional first responders (β = .21, se(β) = .25, p = .033), after accounting for other variables (demographics, stress exposure, social desirability, and compassionate love). predictors in the final model explained 53% of the variance in compassion satisfaction (f(12, 158) = 14.59, rmse = .71, p < table 2 final models of self-compassion and compassionate love predicting mental health in first responders .001). greater compassionate love was associated with greater compassion satisfaction (β = .30, se(β) = .06, p < .001), after accounting for the influence of other variables (demographics, stress exposure, social desirability, service role, and self-compassion). additionally, we observed a significant two-way interaction between self-compassion and service role (β = − .16, se(β) = .16, p = .018), such that greater self-compassion was a predictor of greater compassion satisfaction in traditional first responders (β = .41, se(β) = .07, p < .001), but not in emotional support first responders (β = .04, se(β) = .14, p = .782). predictors in the final model explained 34% of the variance in life satisfaction (f(11, 159) = 7.58, rmse = .84, p < .001). self-compassion was the only significant predictor of interest, with greater self-compassion predicting greater levels of life satisfaction (β = .49, se(β) = .07, p < .001), after accounting for the influence of other variables (demographics, stress exposure, social desirability, service role, and compassionate love). the present study assessed the associations of self-compassion and compassionate love with mental health in a sample of emotional support and traditional first responders. results partially confirmed our hypotheses. contrary to our predictions, we did not observe any interactions between self-compassion and compassionate love. however, consistent with predictions, greater self-compassion was associated with better mental health outcomes. furthermore, compassionate love was protective whenever a significant main effect was observed. additionally, first responders with different roles differed in their level of psychological health, and also the associations of self-compassion with symptoms. specifically, for some outcome variables, traditional first responders reported lower levels of mental health, and selfcompassion played a more important role in predicting their mental health. because prior studies examining compassion in helping professionals have focused primarily on populations with less dangerous occupational duties, we explored differences in the impact of self-compassion and compassionate love on first responders who primarily provide mental health services compared to traditional first responders. exploratory analyses found that the impact of self-compassion differed according to first responder group on two outcomes, and the influence of compassionate love did not differ according to first responder group on any outcomes. for traditional first responders, but not for emotional support first responders, greater selfcompassion predicted a greater sense of personal accomplishment and more compassion satisfaction. this suggests that, under some circumstances, self-compassion may be a more important protective factor for traditional first responders compared to emotional support first responders. however, for most mental health outcome measures, the impact of self-compassion and compassionate love did not depend on the type of service provided. furthermore, when no interaction was present, we interpreted main effects of service role, and found that traditional first responders were more at risk for experiencing negative psychological outcomes (i.e., greater emotional exhaustion and lower resilience), even after controlling for other predictors in the model. although we controlled for frequency of recent stress exposure and variety of trauma related history, traditional first responders might still be exposed to more potential traumas that directly threaten their safety, and this may explain the remaining difference in symptoms. given the differing role of emotional support first responders (i.e., providing on-site emotional support when called to a scene, such as in the case of a sudden death of a family member) and the high risk of injury that traditional first responders face (reichard and jackson 2010), we suspect there may have been meaningful but undetected differences in their experiences of stressors. in cases where the interaction between self-compassion and service role was non-significant, we examined the main effect of self-compassion. consistent with prior findings suggesting that self-compassion in first responders protects against mental health issues such as depression and promotes resilience (bilsker et al. 2019; kaurin et al. 2018) , we observed that self-compassion protected against general psychological distress, post-traumatic stress, secondary traumatic stress, depersonalization, and emotional exhaustion. additionally, we observed that self-compassion was related to greater resilience and life satisfaction. although prior studies suggested positive effects of self-compassion on mental health among members of the general population and helping professionals (macbeth and gumley 2012; raab 2014; zessin et al. 2015) , very few studies have been conducted among first responders. to date, only three published studies were conducted with first responders, two of which primarily focused on depression and resilience as outcomes (bilsker et al. 2019; kaurin et al. 2018) , and the third did not directly assess the relationship between self-compassion and mental health (beaumont et al. 2016c) . the present study confirmed the protective role of self-compassion for a broad array of mental health outcomes across a wide range of first responders. main effects of compassionate love were also observed, even after accounting for the influence of other important predictors (e.g., self-compassion, social desirability). according to our results, compassionate love protected against depersonalization and was associated with a greater sense of personal accomplishment and compassion satisfaction. thus, our results were consistent with prior findings of other-compassion predicting psychological health, such as the observation that mindful other-compassion predicted greater compassion satisfaction and lower burnout in health professionals (beaumont et al. 2016a) . however, it is also important to note that compassionate love for others did not independently predict any of the other psychological outcomes evaluated in the present study, such as general psychological distress, post-traumatic stress, or secondary traumatic stress. these null findings were consistent with studies that observed no relationship between other-compassion constructs and psychological symptoms, such as no relationship between compassionate love and symptoms of depression and ptsd in veterans (kearney et al. 2013) and no relationship between empathy and secondary traumatic stress in police officers ). on the other hand, our results did not align with the subset of studies, which found that other-compassion constructs were potential risk factors, such as the observation that empathy predicted burnout in police officers ) and that mindful other-compassion predicted secondary traumatic stress in mental health professionals (mantelou and karakasidou 2019) . it is possible that we did not observe an association between compassionate love and psychological symptoms because these studies operationalized other-compassion differently (i.e., not as compassionate love). given the overlap between compassionate love, mindful other-compassion, and empathy (hwang et al. 2008; pommier et al. 2019 ), we expected to observe similar findings. however, it is possible that the differences in our operationalization (e.g., compassionate action in addition to empathic feelings, and a focus on strangers) led to different findings. furthermore, discrepant findings could also be due to using different measures of secondary traumatic stress (e.g., proqol vs stss), or to sampling from different populations. the present study has several limitations. firstly, we used a convenience sample of first responders based on our community contacts. this limits the generalizability of our results, as our sample may not be representative of the full first responder population. however, the breadth of our sample exceeds that of prior research with first responders (e.g., kaurin et al. 2018) . our sample also included first responders of different roles, but the sample size for emotional responders was limited. thus, results comparing across groups were only powered to detect larger effects, and results may have been affected by differences in variance in the outcome measures for one group versus the other. additional effects might be detected in future studies with a larger sample size. moreover, we observed demographic differences by service role and attempted to control for these differences by including demographic measures in our models. however, statistical controls are imperfect corrections for study design limitations, and the demographic differences might still have influenced the observed effects of service role. furthermore, the current study was cross-sectional, so our results could not determine direction of causality. limitations also exist in relation to our reliance on self-report measures. despite our attempts to protect participants' anonymity and control for social desirability, it is still possible that other potential problems with self-report, such as limitations in insight or retrospective recall biases, influenced self-reported responses. furthermore, given the demonstrated value of controlling for social desirability, researchers should also consider other scales, such as the paulhus deception scales (pds), which can provide more nuanced information about the influence of both deliberate and nondeliberate socially desirable responding (paulhus 1998) . additional limitations exist in relation to the specific selfreport measures we used. our stress exposure control variables did not assess recent exposure to specific potentially traumatic events. future research should assess if compassion is particularly influential depending on exposure to specific stressors, such as those involving life threat or moral injury. moreover, our mental health measures assessed symptoms across different time frames (e.g., past week/month), limiting our ability to compare results across outcomes. additionally, our personal accomplishment scale showed low internal consistency in the current study, so these results should be interpreted with caution and replicated using a more reliable measure. there were also notable limitations associated with our compassion measures. the validity of the scbcs has been questioned, given the mindful aspects of compassion which the scale does not assess, as well as the scale's reliance on respondents' ability to interpret the word "compassion," which is used in two of its items (strauss et al. 2016) . although this measure was useful given its focus on interactions with strangers, future research could better compare the influences of self-and other-compassion by using measures based on more closely aligned definitions of compassion (such as a mindfulness-based definition for both ; neff 2003; pommier et al. 2019) . additionally, questions were recently raised concerning whether a total score should be used to assess self-compassion as a protective factor, with critics suggesting creating separate scores for positively and negatively worded items (muris and otgaar 2020) . according to post hoc analyses, our results were generally consistent when using either score, supporting self-compassion's role as a protective factor and suggesting that both sets of items contribute to the predictive power of the total score (see supplementary materials). despite limitations, the present study provided evidence suggesting that mindful self-compassion and altruistically oriented compassionate love might serve as protective factors for first responders, a population frequently exposed to potentially traumatic events. the strong beta weights of our variables of interest, even after including several control variables, indicate that self-compassion, compassionate love, and service role could be important predictors of first responders' mental health (see table 2 ). results suggest that self-compassion is particularly important for predicting psychological symptoms (e.g., general psychological distress), and compassionate love is particularly important for predicting outcomes related to engaging in work as a helping professional (e.g., aspects of burnout). given previous findings relating burnout to poor work performance and high turnover (swider and zimmerman 2010) , our results suggest that compassionate love could be important in supporting first responders' abilities to better serve their communities. pending longitudinal research, results suggest that compassion-focused interventions could be beneficial for protecting the mental health of first responders. the online version contains supplementary material available at https://doi.org/10.1007/s12671-020-01527-y. author contributions mollie a. mcdonald contributed to formulating the research question, data analysis, and interpretation, and writing all parts of the article. samantha j. meckes contributed to data analysis and interpretation. cynthia l. lancaster provided mentorship for the first author's completion of this project; she contributed to study design, data collection, data analysis and interpretation, and manuscript writing and editing. all authors approved the final version of the manuscript for submission. funding this research was funded by nevada undergraduate research awards at university of nevada, reno. conflict of interest the authors declare that they have no conflict of interest. research involving human participants and/or animals all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (institutional review 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empathy, and subjective well-being among college students and community adults compassion satisfaction and compassion fatigue among medical social workers in korea: the role of empathy the relationship between self-compassion and well-being: a meta-analysis publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-018401-josb16pi authors: kumaraswamy, priyadharshini; sethuraman, swaminathan; yakhmi, jatinder vir; krishnan, uma maheswari title: hierarchical self-assembled peptide nano-ensembles date: 2014-03-01 journal: handbook of nanomaterials properties doi: 10.1007/978-3-642-31107-9_23 sha: doc_id: 18401 cord_uid: josb16pi a variety of peptides can be self-assembled, i.e. self-organized spontaneously, into large and complex hierarchical structures, reproducibly by regulating a range of parameters that can be environment driven, process driven, or peptide driven. these supramolecular peptide aggregates yield different shapes and structures like nanofibers, nanotubes, nanobelts, nanowires, nanotapes, and micelles. these peptide nanostructures represent a category of materials that bridge biotechnology and nanotechnology and are found suitable not only for biomedical applications such as tissue engineering and drug delivery but also in nanoelectronics. self-assembly is defined as a process where individual components form organized structures via specific and local interactions without any external intervention [1] . molecular self-assembly is a spontaneous process where the molecular components organize into ordered structures through non-covalent interactions such as van der waals, hydrophobic, capillary forces, electrostatic forces, or hydrogen bonds [2] . although these interactions are relatively weak when compared to covalent bonds, they form reasonably stable higher-order structures through self-assembly due to the additive effect of these secondary forces. in other words, these self-assembled structures are thermodynamically more stable due to lower values of gibbs free energy when compared to that of the individual components (building blocks). since the underlying interactions are rather weak, any external stimulus can alter the self-assembled structures. however, once the stimulus is removed, they can revert back to their original structure. molecular self-assembly is ubiquitous in nature, and it has evolved in many areas including chemical synthesis, nanotechnology, polymer science and materials science, and engineering [3] [4] [5] [6] [7] [8] [9] . the molecular level self-assembly is a typical example of the 'bottom-up' approach where molecules in the sub-nm range come together to form assemblies that are in nm or bit larger in dimensions [10, 11] . numerous self-assembling systems ranging from diand tri-block copolymers, complex dna structures, simple and complex proteins, and peptides have been developed [12] [13] [14] [15] [16] [17] [18] [19] [20] . complex and intricate monodisperse structures can be obtained through self-assembly with high precision and reproducibility. biomolecules possess an inherent ability to form hierarchical self-assemblies in aqueous medium. biomolecules such as proteins, deoxyribonucleic acid, and lipids have been widely investigated for their self-assembling properties [21] [22] [23] [24] [25] [26] [27] . in fact, these three biomolecules form the 'molecular trinity' of biomolecular self-assembly. peptide systems have been especially popular self-assembling systems due to the large number of structures that can be generated by slight modification of the number and nature of amino acid residues in the sequence [8, 28, 29] . the stability, ease of synthesis, and controlled self-assembly regulated by various physicochemical parameters have resulted in the popularity of selfassembled peptide systems [30] . since peptide self-assembly is a bottom-up process where amino acids form the building blocks, it is easy to introduce functionalities on the carboxyl or amine terminal groups, opening up the possibilities of a wide range of chemical interactions leading to specific functions. though peptides containing naturally occurring l-amino acids have been widely investigated for their self-assembling characteristics, d-amino acid containing peptide systems have also been explored due to their stability against proteases [31] . self-assembling peptides may vary in the number of amino acids starting from 2 to as high as 20. the simplest building block reported thus far is the dipeptide (diphenylalanine -ff) from the core recognition motif of alzheimer's amyloid beta peptide [32] . this dipeptide is reported to form different structures based on the ph that is employed (fig. 8.1 ). for instance, at a ph lower than the isoelectric point of the peptide, it forms nanofibrils, whereas at a ph higher than its isoelectric point, the peptide forms nanotubes [33] . despite the numerous advantages of self-assembling peptides, there are several challenges associated with their use in biomedical applications, which include problems related to processability, control of size, functionalization, and stability in aqueous media [34] . for example, biosensing platforms employing self-assembling peptides require electric contacts between the selfassembled nanostructures and transducers, which become tedious due to the small dimensions involved. however, with the advancement in micro-and nanofabrication techniques, such problems are being overcome, paving the way for use of peptide nanostructures in molecular electronics. another impediment relates to the low conductivity of the self-assembled peptide nanostructures, which limits their use in sensing and diagnosis. however, by the introduction of conductive polymers, enzymes, and metallic particles, the electrical current conductivity can be enhanced [31, 35] . the self-assembly process is influenced by many factors that can be grouped into any of the three categories, namely, environment-driven factors, substrate-driven factors, and peptide-driven factors. the ph, temperature, solvent, nature of ions, and ionic strength are factors that influence the self-assembly process. the ph of the medium alters the charge status on the peptide and hence the electrostatic forces between the peptide molecules. for instance, the peptide stviie forms beta-sheets when its net charge is +1, whereas in its zwitterionic state, it forms random coils and it exists as a mixture of random coils and beta-sheets when the net charge is à1. this is because when the net charge is zero as in the zwitterionic form, the packing of the peptides could happen in many ways leading to an amorphous structure. the presence of a net charge gives directionality to the associations as well as determines the distance between the peptide chains [36] . the charge distribution in the peptide also influences the self-assembled structures formed. for example, when the peptides eak 16-i (aeakaeakaeakaeak), eak 16-ii (aeaeakakaeaeakak), and eak 16-iv (aeaeaeaeakakakak) were self-assembled, it was found that eak 16-i and eak 16-ii formed fibrillar assemblies, while eak 16-iv formed globular structures between ph 6.5 and 7.5 and fibrillar structures at other ph due to the neutralization of charges in the beta-sheet structures formed, which promotes aggregation at ph away from the neutral ph [37] . the nature of anion also was found to influence the structures formed by the eak 16-ii peptide in the presence of cu 2+ ions. while so 4 2caused formation of nanofibers, the monovalent cland no 3 caused formation of short fibrils with a mixture of alpha helix and random coils. this is due to the ability of the divalent sulfate anions to act as an electrostatic bridge between two lysine residues unlike the monovalent ions. higher ionic strength of the medium contributes the shielding of the electrostatic charges on the ionizable groups present in the peptide sequence, thereby altering the critical aggregation concentration as well as the ph required for association or dissociation of the self-assembled structure [37] . factors like the solvent polarity, surface tension, hydrogen bond-forming ability, and dielectric constant influence the peptide self-assembly and strength of the self-assembled structures. introduction of methanol as cosolvent contributed to the formation of nanofibers of diphenylalanine (ff) on a glass substrate. this was attributed to the high hydrogen bond donor and acceptor property of methanol that promoted formation of highly crystalline nanofibers [38] . on increasing the methanol content, solvation of the peptide molecules occurred, which prevented aggregation of the solvated peptide. it was also observed that organic cosolvents with higher surface tension contributed to reduction in fiber dimensions to the nm range. the dielectric constant of the solvent has been found to influence the peptide substrate binding affinities [39] . the surface tension, hydrophobicity, and surface texture of the substrate influence the self-assembly process. hydrophobic substrates promote better spreading of peptide sequences that have greater number of hydrophobic residues. surface topography, on the other hand, directs the orientation as well as fiber dimensions. the dipeptide ff was found to self-assemble into nanofibers with a well-spread morphology on poly(vinyl chloride), whereas in silicon, which had a periodic rough texture, finer fibers were observed along with vertically aligned hollow nanotubes of larger dimensions suggesting that the rough morphology retards the stacking interactions between the peptide molecules [34] . peptide-driven factors that direct self-assembly are the number and nature of amino acid residues in the sequence, the isoelectric point, and the peptide concentration [40] . aromatic residues led to the formation of rigid structures that possessed nanotape or nanoribbon morphology [41] . reduction in the surface tension of the peptide molecule can lead to the formation of globular assemblies instead of fibrillar structures as observed with the peptide eak 16-iv at neutral ph. peptide aggregates are formed above a particular concentration known as critical aggregation concentration (cac), which in turn is dependent on the peptide sequence. below the cac, the seeding and nucleation occur, while above cac, the aggregated ensembles are discernible [42] . in the case of surfactant-like peptide amphiphiles, if the surfactant number is between ⅓ and ½, then cylindrical micelles and nanofibers are observed ( fig. 8.2 ). however, if the surfactant number is between ½ and 1, then bilayer formation occurs. in the case of micelle-forming peptides, increase in the intermolecular cross-links has been found to reduce the curvature leading to the formation of cylindrical micelles as observed in the hexadecyl-modified peptide sequence ccccggg phosphoserine-rgd [43] . peptides that self-assemble are amphiphilic and are classified based on their nature of self-assembly. peptide lego systems consist of both hydrophilic and hydrophobic residues that form beta-sheet structures and well-defined nanofiber matrices with an average pore size of 5-200 nm in aqueous solution. these peptides are termed as molecular lego peptides as they possess alternating charged and hydrophobic amino acids like the pegs and holes of lego blocks. for example, in the peptide rad 16-i, the sequence is radaradaradarada, where r (arginine) is a cationic amino acid and d (aspartate) is an anionic amino acid. these oppositely charged amino acid residues are separated by a hydrophobic amino acid residue, alanine. the charge status of the peptide sequence will therefore be represented as (+ à + à + à + à + à + à + à + à), and such sequences are referred to as modulus i peptides. similarly, modulus ii (++à à++à à) and modulus iii (+++à à à+++à à à) have also been reported based on their charge pattern. these peptides spontaneously form nanofibers of 10 nm length in the presence of cations of alkaline earth metals due to electrostatic forces. since ionic interactions are involved in the self-assembly process, the molecular lego peptides readily form hydrogels [44] . the hexadecapeptide dar 16-iv with the peptide sequence dadadadarararara has similar amino acid residues as rad, with the only difference that the sequence of the charged amino acid residues varies. this difference is markedly reflected in the self-assembled structures formed by the two peptides. the self-assembled structures formed by dar 16-iv can transform from an alpha helix to a beta-sheet depending on the ph, ionic strength, and temperature i does not form alpha helical structures under any condition. this is because in the case of rad 16-i, if the peptide assumes an alpha helical structure, the positively charged side groups in arginine (r) will be repelled by the positively charged n-terminus, and the anionic aspartate (d) will experience electrostatic repulsion from the like-charged carboxylate in the c-terminus. hence, it always remains in the beta-sheet form. in the case of dar 16-iv, the negatively charged aspartate will stabilize the positive n-terminus, and the positively charged arginine will exhibit electrostatic attraction with the negative c-terminus when it adopts an alpha helical form. thus the nature, number, and sequence of amino acids are critical parameters that determine the type of self-assembled structures that can be formed by peptides [45] . the molecular lego peptides are also known as ionic self-complementary peptides due to their pattern of electrostatic association that contribute to their stability. zhang and his coworkers identified the first molecular lego peptide eak-16 from a z-dna binding protein zuotin from yeast [36] . the ionic self-complementary peptides initially form beta-sheets, which later form a fibrous network, progressively by undergoing sol-gel transition. the substitution of a basic amino acid with another basic amino acid (for instance r with k) or an acidic amino acid with another acidic amino acid (e.g. d with e) does not bring about significant changes in the self-assembly pattern. however, substitution of an acidic amino acid with a basic amino acid and vice versa was found to alter the self-assembly pattern. such structures were found to form beta-sheets but did not form higher-order structures. substitution of the alanine residues with more hydrophobic residues such as leucine, valine, and isoleucine accelerates the self-assembly process [46] . surfactant-like peptides self-assemble either into nanotubes or nanovesicles [47] [48] [49] [50] (fig. 8.3 ). they are termed as surfactant-like due to the presence of a hydrophilic head comprising charged amino acids (lysine, arginine, glutamic acid, aspartic acid, etc.) and a hydrophobic segment comprising nonpolar amino acids (alanine, leucine, valine, etc.). intermolecular hydrogen bonding plays a major role in determining the structures formed by the self-assembly of these peptides. vauthey et al. were the first to design a self-assembling peptide that can self-assemble into nanotubes and nanovesicles [47] . some common examples of surfactant-like peptides include a 6 d, v 6 d, v 6 d 2 , l 6 d 2 15, and g 6 d 2 . these peptides initially self-assemble to form a bilayer, which later undergo further associations to form nanotubes. the nature of the amino acids in the sequence has an important role in dictating the type of self-assembled structures formed. the peptide sequences a 6 k and a 6 d both formed nanotubes often exhibiting twisted tape or fibrillar morphology. a heptapeptide, namely, ac-gavilrr-nh 2 , formed donut-like ring structures [46] . peptides like v 6 d 2 , v 5 dvd, and v 4 d 2 v 2 have been reported to form fibers, tapes, and twisted ribbons rather than nanotubes. the differences in the self-assembled structures formed could be attributed to the variations in the packing density of the peptide aggregates [51] . the number of hydrophobic amino acids in each surfactant-like peptide also influences the final self-assembled structure. three peptides a 3 k, a 6 k, and a 9 k, with different hydrophobic chain lengths were investigated for their self-assembling properties [52] . while a 3 k formed stacked bilayers, a 6 k formed nanofibers and a 9 k formed nanorods. the absence of higher-order structures in a 3 k peptide was attributed to the absence of measurable critical aggregation concentration (cac), probably due to the short hydrophobic segment. several surfactant-like peptides found in nature also exhibit similar self-assembling characteristics to form vesicular structures that may be relevant to prebiotic enclosures that sequester enzymes from their environment [53] . the lipid-like peptides are a subtype of surfactant-like peptides and consist of a hydrophilic head group and a tunable hydrophobic tail. though the lipid-like peptides possess different composition, sequence, and packing, they share several similarities with phospholipids that self-assemble to form lipid bilayers. the length of the peptide is about 2.5 nm, which is comparable to natural phospholipids. both systems self-assemble in water to form nanovesicles with an average diameter of 30-50 nm. a point of distinction between the two systems is in the nature of association between the individual components. in phospholipids, the acyl chains in the hydrophobic tails compactly pack together to displace water molecules from the interior and hydrophobic forces drive this process, which impedes formation of hydrogen bonds. however, in the case of lipid-like peptides, in addition to the hydrophobic tail packing, intermolecular hydrogen bonds are formed in the backbone. the presence of charged side chains in these peptides confers ph sensitivity as well as responsiveness to change in the ionic strength of the medium. carpet peptides also known as molecular paint peptides were first developed by zhang et al. [54] . these peptides can undergo self-assembly and form monolayers, a few nanometers thick on a surface. these peptides thus act as a carpet for the attachment of cells or they can trap other molecules, thereby providing molecular recognition ( fig. 8.4 ). these peptides consist of three segments. the first segment or head contains ligands that serve as molecular recognition motifs for cell surface receptors. the middle segment serves as a linker that allows the head to interact at a distance away from the surface and also provides certain degree of flexibility to the peptide structure. the last segment or tail enables covalent binding with the surface. these peptides are widely used to study cell-cell communication. the peptide sequence rgdaaaaac is a typical example of a molecular paint peptide [54] . the rgd segment serves as a recognition motif for the cell surface receptors integrins and hence can promote cell adhesion. the five alanine residues (aaaaa) serve as linkers, while the lone cysteine residue can enable anchoring of the peptide to gold substrates through its sulfhydryl group. similarly, the tetradecapeptide radsradsaaaaac that also possesses a ligand (rads) for cell recognition has been developed for painting gold surfaces [55] . the switch peptides possess a unique ability to transform its molecular structure in response to environmental stimuli. for example, the hexadecapeptide dar16-iv can form beta-sheet structures at ambient temperatures but transforms to an alpha helix when the temperature or ph of the system is modified. this suggests that secondary structures of sequences flanked by the negative charges on n-terminus and positive charges on c-terminus may undergo drastic changes if the ph and temperature are changed. these peptides were converted to electronically responsive structures through incorporation of metal nanocrystals [56] . an undecapeptide with the sequence ac-qqrfqwqfeqq-nh 2 was found to self-assemble into structures with progressively increasing order -tapes, ribbons, fibrils, and finally fibers [57] (fig. 8.4) . the side chains of the glutamine (q) residues involve in hydrogen bonding and promote formation of b-sheets. the arginine (r) and glutamate (e) residues facilitate electrostatic interactions with the complementary countercharges on the neighboring chains leading to stabilization of antiparallel b-sheets forming a tape-like structure. the phenylalanine (f) and tryptophan (w) residues contribute to hydrophobic forces that drive the formation of ribbons. in the ribbon-like morphology, two tapes associate face-to-face stabilized by the hydrophobic forces leading to a twist. at higher concentrations of the peptide, the ribbons stack together to form fibrils. the substitution of the glutamine residues with glutamate (e) in the peptide sequence induces ph responsiveness in the peptide. at acidic ph (<2), the glutamate residue is protonated and hence will exhibit associative interactions promoting the existence of a nematic phase. as the ph is increased, the glutamate residues get deprotonated, and hence greater repulsive forces are introduced leading to transformation of the nematic phase to an isotropic fluid phase. thus the peptide acts as a molecular switch in response to ph changes by transforming reversibly between nematic and isotropic fluid phases. the design of cyclic peptides, whose dimensions and assembly could be tailored as desired, was inspired from the tubular pores formed by the tobacco mosaic virus [58] . ghadiri and his coworkers were the first to report the self-assembly of a rationally designed cyclic octapeptide cyclo(l-gln-d-ala-l-glu-d-ala-) 2 [59] . these cyclic peptides have alternating d-and l-amino acids, which interact through intermolecular hydrogen bonding to form an array of self-assembled nanotubes with an internal diameter of 7-8 å (fig. 8.5 ). the diameter of the tube depends on the number of amino acid residues forming the cyclic peptide. at alkaline ph, the carboxylate groups of glutamate residues become negatively charged as a result of deprotonation and prevent stacking associations due to strong electrostatic repulsive forces. at acidic ph, the carboxylate groups become protonated and hence favor association through extensive hydrogen bonding between the amide carbonyl and -nh-groups in the backbone. each cyclic peptide forms a flat ring that stacked over one another and is stabilized by hydrogen bonding resulting in a hollow nanotube. the side chains of the amino acids face the exterior of the tube to minimize steric repulsions. these side chains can also be functionalized to incorporate desired properties to the nanotubes. the cyclic octapeptide lanreotide nh 2 -(d)naphthylalanine-cys-tyr-(d) trp-lys-val-cys-thr-conh 2 , an analogue of somatostatin 14, also self-assembled into tubular structures with a diameter of 24 nm and length running to several microns [60] . this category of peptides represents a hybrid molecule formed from oligonucleotides and amino acids. the sequence of both components influences the nature of self-assembly. gour et al. have reported the self-assembly of a nucleopeptide formed by grafting the dipeptide ff to the 12-mer oligonucleotide with sequence ctctctctcttt [61] . the diphenylalanine (ff) is part of the core recognition motif of the amyloid peptide and self-assembles to fibrillar structures in its pristine state. however, the nucleopeptide formed using this peptide motif self-assembled to spherical structures, which may be attributed to the hydrogen bonding interactions and amphiphilicity of this hybrid molecule. li et al. had developed nucleopeptides that self-assemble to form supramolecular hydrogels using the dipeptide ff conjugated to a nucleobase (a, g, t, or c). these nucleopeptides served as hydrogelators forming entangled nanofibers in water and could lead to many interesting biomedical applications [62, 63] . peptide amphiphiles comprise of a hydrophilic head and hydrophobic tail that self-assemble in aqueous solution to form well-defined nanostructures like peptide bilayers, micelles, nanotubes, nanorods, and nanovesicles [64] [65] [66] . these molecules can be chemically modified easily to tailor their properties for specific applications such as cell adhesion and internalization. the mechanistic insights into the self-assembly of peptide amphiphiles using v 6 d as a model have suggested that the peptide amphiphile initially self-assembles into a bilayer and then into a cyclic vesicular form that undergoes stacking to form nanotubes. it has also been suggested that higher-order structures could be obtained by interconnection of these tubes through three-way junctions [67] . most of the peptide amphiphiles form betasheet containing nanofibrils that can be induced either by addition of divalent salts or by altering the ph of the solution. the divalent cations form an ion bridge leading to stronger intra-and interfibrillar associations. experiments have revealed a high degree of solvation in the interior of the self-assembled structures formed by peptide amphiphiles [44] . incorporation of a cysteine residue in a peptide sequence promotes reversible cross-linking of the peptide leading to modification of the stiffness of the peptide chain. another strategy to impart amphiphilic character to the peptide sequence is to incorporate a fatty acyl chain to the n-terminus of a peptide sequence. the acyl chain contributes to the hydrophobic character to the peptide amphiphile. using an elegant set of experiments, lowik et al. demonstrated the influence of alkyl chain length on the self-assembly of the peptide ganpnaag [68] . the peptide molecules modified with c 6 , c 10 , and c 12 acyl chains self-assembled into random coils independent of temperature, while those containing c 14 and c 16 acyl chains underwent a transition from b-sheets to random coils on increasing the temperature. increasing the acyl chain length contributes to enhanced hydrophobicity leading to differences in the thermal stability. in a seminal work, hartgerink et al. developed a peptide amphiphile with four distinct domains that self-assembled into cylindrical micelles in aqueous solution [69] . the n-terminus of the peptide sequence cys-cys-cys-cys-gly-gly-gly-phosphoser-arg-gly-asp was modified with a 16-carbon alkyl chain that forms the hydrophobic component. the cysteine residues contribute to the formation of b-sheets and stabilize the self-assembled structure by covalent capture where superstructures are transformed into a supramolecule through covalent bonding. the disulphide bridges formed due to the oxidation of the cysteine residues confer rigidity to the supramolecular structure. further, stabilization of the structure is provided through extensive hydrogen bonding. the glycine-rich segment forms the flexible spacer domain. the phosphoserine residue confers charge and hence ph responsiveness to the sequence, while the rgd serves as a recognition motif for cell adhesion. this peptide amphiphile associated at acidic ph and dissociated at alkaline ph ( fig. 8.6 ). similar analogues have now been developed for many biological applications. reverse peptide amphiphiles like c16o-veve with a free n-terminus were prepared using unnatural amino acid (ornithine, o) modified with a fatty acid chain and were mixed with conventional peptide amphiphiles containing free c-terminus. such de novo designed peptide amphiphiles formed nanobelts [70] . a twisted nanoribbon morphology was observed when the cell adhesion motif rgd was incorporated in the c-terminus (c16o-vevegrgd). apart from normal method of peptide synthesis, recombinant dna techniques have also been employed to produce two amphiphilic peptides, namely, ac-a 2 v 2 l 3 wg 2 -cooh and ac-a 2 v 2 l 3 wg 7 -cooh, which self-assembled into nanovesicles [71] . a bolaamphiphilic peptide consists of two hydrophilic terminals linked through a hydrophobic segment. this class of peptides derives its name from the south american hunting weapon that consists of two balls linked by a string. stupp and his coworkers reported the self-assembly of a bolaamphiphilic peptide consisting of glycylglycine (gg) residues at either end linked through a 7-carbon acyl chain [72] ( fig. 8.7) . the bolaamphiphilic peptides were ph responsive and formed helical ribbon-like structures at alkaline ph. the hydrophobicity of the acyl chain in the middle influences the twist in the structure so as to minimize contact with the polar environment. at acidic ph, the peptide self-assembles to form nanotubes presumably due to the additional hydrogen bonds formed through the protonated carboxylic groups of the amino acid residues. crick, in 1953, first reported coiled-coil structures, commonly seen in many proteins. the major driving force is the hydrophobic interaction among the helices and a typical coiled structure consists of 2-5 left-handed alpha helices containing seven amino acid residues (heptad), each wrapped around each other to form a supercoil. according to the peptide velcro (pv) hypothesis, there are three major requirements for formation of such structures [54] . the first and fourth residues must be hydrophobic to facilitate dimerization of the peptide chains along one face of the helix. the length of the hydrophobic side chain dictates the formation of dimers, trimers, or tetramers. increasing hydrophobicity stabilizes the self-assembled structure through van der waals' and hydrophobic interactions. the fifth and seventh amino acid residues should have charge to promote electrostatic interactions between the peptide chains. in order to facilitate attractive associations, it is important to have an acidic and a basic amino acid residue at these positions. leucine zipper proteins and cartilage oligomeric matrix proteins exhibit such type of coiled-coil structures. a right-handed alpha helical coiled-coil structure has also been identified in tetrabrachion, a protein from the bacterial staphylococcus marinus. this structure contains undecapeptide helices that possess a core filled with water, thereby exhibiting a different packing pattern with the hydrophobic and hydrophilic residues in the first, fourth, and eighth positions falling on the same face [73] . apart from peptide velcro where one strand of acidic amino acid residues mingles with other strand of basic residues to form a parallel heterodimer, ryadnov et al. have designed belts and braces where two peptides are bound together by the third peptide of opposite charge. these belt and braces were used as a template to form colloidal gold particles and were commonly referred as peptide-mediated nanoparticle assembly [74] . other types of self-assembled peptide systems include amphiphilic peptides in beta strand conformation which self-assemble into twisted tapes, helical dipolar peptides that undergo conformational change between a helix and beta-sheet similar to molecular switch, and surface binding peptides that form monolayers that are covalently bound to a surface. table 8 .1 gives a list of some of the major peptide systems investigated for their self-assembling properties. formation of nanotubes and vesicles [48] v 6 k, v 6 k 2 , v 3 k adsorption at air/water interface used for dna immobilization [75] v 6 k 2 , l 6 k 2 , a 6 k, v 6 h, v 6 k, h 2 v 6 , kv 6 formation of nanotubes and vesicles [48] ac-a 6 d-cooh and ac-a 6 k-cooh determination of critical aggregation concentration (cac) of particles formed during self-assembly [66] mixtures of ac-a 6 d-oh and ac-a 6 k-nh 2 formation of twisted fibrils [76] ac-ga vilrr-nh 2 formation of 'nanodonut' structures [46] correlation of secondary structure with the morphology of nanostructures formed [67] influence of sequence and purity on self-assembly [51] a 3 k, a 6 k, a 9 k determination of cmc, self-assembled structures, correlation with its antibacterial activity [52] a 6 k elucidation of nanotube structure and its mechanism of formation [77, 78] ac-a 2 v 2 l 3 wg 2 -cooh and ac-a 2 v 2 l 3 wg 7 -cooh formation of vesicles [71] chol-h 5 r 10 , chol-h 10 r 10 (chol denotes cholesterol) vehicles for delivering genes [79] a 12 h 5 k 10 , a 12 h 5 k 15 , and h 5 k 10 (non-amphiphilic control) vehicles for delivering genes [80] ac-(af) 6 vehicles for delivering genes [82] chol-g 3 r 6 tat, tat ¼ ygrkkrrqrrr antimicrobial activity [83] a 6 d and a 6 k stabilization of g-protein-coupled receptor bovine rhodopsin against denaturation [82, 84] ac-v 6 r 2 -nh 2 , ac-v 6 k 2 -nh 2 , ac-a 6 k-nh 2 , ac-i 6 k 2 -nh 2 , ac-a 6 k-oh, da 6 -nh 2 , ac-v 6 d 2 -nh 2 , ac-a 6 d-oh, ka 6 -nh 2 stabilization of protein complex photosystem-i and enhancement of activity [64] where sl denotes the spin label acetamidoproxyl micelle aggregation and formation of particles and beads [85] the formation of nanofibers can be promoted by peptides that have an ability to form beta-sheets. presence of branched amino acid residues confers an ability to transform from a a-helical structure to a b-sheet depending on the nature of the medium [86] . the propensity of beta-sheet forming ability of peptide sequences can be retarded by introduction of proline residues at the n-and c-terminals. as proline lacks hydrogen bond-forming ability owing to its planar ring structure, it restricts the expansion of the beta-sheet network. this results in formation of straight nanofibers of about 80-130 nm in diameter and several mm long. the fine structure will show striations arising due to packing of tightly coiled alpha helical structures, especially if phenylalanine was one of the amino acid residues in the sequence. this is due to additional aromatic interactions contributed by phenylalanine. if phenylalanine was substituted by aliphatic hydrophobic residue such as isoleucine, the straight fibers formed revealed tape-like inner structures. attempts to functionalize these nanofibers to impart biorecognition have been made using biotin conjugation at their n-terminus [87] . these biotin terminals can be used to tether molecules linked to anti-biotin molecules. however, such functionalization strategies resulted in a loss of the supramolecular assembly formed by the peptide. three main forces, namely, hydrophobic, hydrogen bonding, and coulombic forces, are mostly involved in controlling the self-assembly process [88] . a combination of hydrogen bonding, p-p interactions, and van der waals' interactions promotes formation of columnar, disc-like aggregates, while hydrophobic effects and p-p stacking favor formation of 2d sheets and rectangular aggregates. cross-linking between peptide chains leads to rigid rods, while cross-linking in micellar assemblies leads to reduction curvature, thereby forming cylindrical micelles. rod-shaped structures can further stack to form columnar assemblies as their elongated, anisotropic geometry permits their preferential alignment along one spatial direction [89] . hartgerink had employed three main design principles for customizing the peptide nanostructures that could be formed from cyclic peptide sequences [30, 59] . the cyclic peptide should contain only eight amino acid residues as shorter sequences lead to strained amide backbone, while longer sequences will be flexible. steric interactions between the side chain and the backbone of the heterochiral alignment are prevented by designing the register of the stack in such a way that the rings will align with homochiral residues as their neighbors. side chain-side chain interactions are manipulated using glutamine residues that play a major role in intra-and intermolecular hydrogen bonding interactions. incorporation of non-peptide moieties into a self-assembled ensemble can lead to emergence of novel properties. for instance, the poor conductivity of self-assembled peptide nanostructures, which limits their use in sensing and diagnosis, can be overcome by the introduction of conductive polymers, enzymes, and metallic particles. alignment and positioning of the peptide nanostructures on a solid surface can be achieved through appropriate chemical modification of the substrate surface or peptide nanostructures, or both. atomic force microscopy (afm), dielectrophoresis, or optical tweezers have been employed for making appropriate connection between the self-assembled peptide nanostructures and transducers [90, 91] . sedman et al. have used afm as a thermomechanical lithographic tool to create indents and trenches in the self-assembled nanotubes formed by diphenylalanine and dinaphthylalanine, thus utilizing them as nanobarcodes [92] . reches and gazit have also tried manipulation of the peptide nanostructures using magnetic forces. apart from modification, functionalization of the peptide nanostructures has been carried out by rica and coworkers using dielectrophoresis (dep) for the incorporation of antibody-functionalized peptide nanotube on top of gold electrodes for the development of label-free pathogen detection chip [72] . schnarr et al. have created coiled-coil heterotrimeric assembly by employing electrostatic forces, and this molecular self-assembly is driven by the hydrophobic forces, while the building blocks were matched via electrostatic interactions [93] . many attempts have been made to improve stability of the self-assembled ensembles through cross-linking or enhancing associative forces. recently, selfassembled polymeric vesicles with enhanced stability, specificity, and tunability were formed from amphiphilic block copolymers with alternating hydrophilic and hydrophobic segments [44] . introduction of a polypeptide chain in this amphiphilic block copolymer results in the formation of peptosomes [57, 94] . the peptide segments are mostly associated with the hydrophobic segments resulting in the self-assembly. the peptide wnvfdflivigsiidvilse derived from the calcium channel forming protein caivs3 exhibits adhesive properties and thereby enhanced stability [95] due to the cohesive forces between the chains that are responsible for driving their association even in the absence of water. gudlur et al. had designed two amphiphilic peptides with an oligolysine main chain (k 5 ). the aand e-amino groups were both modified with either the hydrophobic nonapeptide flivigsii (h 9 ) or the hydrophobic pentapeptide flivi (h 5 ). these amphipathic lipid-like peptides when mixed in equimolar quantities (h 9 h 5 ) spontaneously self-assembled to form vesicular structures in an aqueous medium. differential scanning calorimetry studies on the h 9 h 5 peptide vesicles indicated good thermal stability over a wide range of temperature, and no alteration in the structure was observed [95] . a peptide derived from human elastin consisting of hydrophobic repeats pgvgva along with the cross-linking regions composed of polyalanine interspersed with lysine [96] formed highly insoluble nanofibers upon incubation at 37 c. once fibers were formed, the side chain of lysine is converted to an aldehyde by lysyl oxidase enzyme, which then reacts with neighboring primary amines to form dehydrolysinonorleucine that then forms desmosine cross-links. these cross-linked fibers formed from a small peptide fragment of elastin exhibit good mechanical properties like resilience and strain at breaking point. covalent capture is a recently developed strategy that integrates the design and synthesis features offered by non-covalent self-assembly along with structural integrity. this approach involves covalent bond formation for stabilizing the self-assembled supramolecular ensembles without significantly affecting their structure. the formation of covalent bonds can occur before or after self-assembly. the order of self-assembly and the covalent bond formation play an important role in determining the physical structure of the aggregate formed. if the covalent bond is formed before self-assembly, either there will be low yield or the desired molecular aggregate will not be formed. however, if the covalent bond is formed after self-assembly, the pre-organization of reacting species happens, and the covalent bond formation is also enhanced. bilgicer et al. have employed the covalent capture method to dimerize two coiled peptides -one containing a leucine residue and the other an unnatural amino acid hexafluoro leucine at the same specific site [97] . the dimerization of the two peptide sequences containing the natural leucine and unnatural fluorinated leucine hydrophobic residues was achieved by incubating them in a glutathione buffer. characterization of the self-assembled peptide structures for their electrical, physical, and chemical properties is essential to determine their potential in applications. a wide range of characterization tools have been employed to elicit such information on the self-assembled structures (table 8. 2). this effort is intensifying as newer customized protocols become available with time to evaluate the performance and properties of novel peptide ensembles. different types of microscopic tools have been used to visualize the self-assemblies formed by peptides. apart from forming nanostructures, self-assembled peptides also form micrometer scale structures that can be analyzed using polarized light, epifluorescence, and confocal microscopy [98] . while polarized light microscopy deals with birefringence and is employed to investigate the behavior of light-crystalline phases, epifluorescence and confocal microscopy are specific for the peptidic structures involving the fluorophores. polarized light microscopy is used to identify various mesophases like nematic, cholesteric, and cubic involved in the lyotropic behavior of the nanostructures formed from the amino acid units. epifluorescence microscopy is a technique that is widely applied to biological systems. the sample is irradiated with electromagnetic radiation of a particular wavelength known as excitation wavelength and the longer wavelength that is emitted from the sample is then detected. in epifluorescence microscopy, both excitation and observation of the emission occur from above ('epi') the sample. this technique has been applied to detect both intrinsic fluorescence of the peptide structures and the emission from fluorophores linked to the peptide chains. the topography of the self-assembled structures formed by two amphiphilic peptidolipids derived from the 31-35 residues of the amyloid beta peptide (c 18 -iiglm-oh and c 18 -iiglm-nh 2 ) was observed using this technique [99] . studies on the association between the ff nanotubes and pyrenyl derivatives have revealed that the final structure and its photophysical response are found to be dependent on the ph and the fluorophore concentration. when the pyrenyl concentration is low and when the ph is less or equal to 7, the structures formed are shorter and thinner, while at higher peptide concentrations and at alkaline ph, the fibrils formed are thicker [100] . these findings confirm that the final structure is due to the balance between electrostatic and hydrophobic forces. at lower ph, protonation of carboxyl groups of either pyrenyl chromophore or ff molecules occurs, and hence electrostatic interactions become weakened, while the aromatic p stacking between the aromatic rings of the pyrenyl structure dominates. at neutral ph, though the amino groups are protonated, the carboxyl groups of ff and pyrenyl determination of presence of beta-sheet structures. employed in studying the mechanism of amyloid fibril formation surface plasmon resonance spectroscopy atomic force microscopy investigation of the kinetics of self-assembly, conduct structure manipulation, determine the size and morphology of the nanostructures formed during the self-assembly diffraction studies nanofiber alignment and determination of cross b-sheet structures electron microscopy morphology of self-assembled structures gel electrophoresis determination of monomers and its subsequent polymerization into dimers, tetramers, and oligomers circular dichroism determination of secondary structure and transition between secondary structures during self-assembly process fourier transform infrared spectroscopy determination of beta-sheet structures are not protonated, and hence only weak induced dipole interactions are favored. at alkaline ph, both carboxyl and amino groups are deprotonated, and hence electrostatic forces cannot compete with the hydrophobic forces resulting in side-chain contacts to form thicker fibrils [100] . thioflavin t (tht) is a fluorescent molecule that binds to beta-sheet structures of peptide assemblies. the binding results in a red shift in the emission of thioflavin t from 342 to 442 nm. the presence of aromatic residues that contribute to p-p stacking interactions of the aromatic rings in tht with the peptide causes a change in the charge distribution of tht in its excited state causing the red shift [101] . the rigidity of the peptide structure and its flatness are additional factors that contribute to tht binding. one of the limitations of tht is its poor solubility in aqueous solvents. to overcome this issue, a sulfonated analogue thioflavin s (ths) has been introduced with sulfonated groups [102] . congo red is yet another fluorescent probe that has exhibited selective binding to the beta-sheets of amyloid and amyloid-like fibrils [103] . confocal laser scanning microscopes (clsms) provide high in-plane resolutions by restricting entry of out-of-focus light by employing a pinhole for illumination of a sample, thus making it an attractive tool for investigating peptide self-assemblies. they are mainly used in 3d reconstruction of images recorded at different slices along the z direction. the imaging of the peptide nanostructures formed has been accomplished by using confocal laser scanning microscopy (clsm). ff microtubes labeled with rhodamine b were imaged using clsm [104] , and this technique has been used to identify the hydrophobic-rich and hydrophilic-rich regions by labeling ff structures with two fluorescence dyes, namely, rhodamine and phthalocyanine. since rhodamine is relatively hydrophilic, it was localized in the inner core of the peptide assembly, which consists of hydrophilic clusters. phthalocyanine was found in the hydrophobic external wall of ff nanostructures. the clsm enabled visualization of both the hydrophilic and hydrophobic clusters by reconstructing the images in 3d. similarly, the distribution of the peptide amphiphiles c 16 -vvvaaaggklakklakklakklak and c 16 -vvvaaakkk in a hyaluronic acid membrane was imaged using clsm [105] . the peptide amphiphiles were modified with a fluorophore at the n-terminus to enable imaging. the z-sectioning served to understand the localization of the peptide self-assemblies within the membrane. the effect of the nanofibers formed by the self-assembly of glucagon-like peptide 1 (glp-1) mimetic peptide amphiphiles on the cell viability and proliferation of rat insulinoma cells were investigated using clsm. the clsm technique has been extensively used as a powerful tool to investigate cell morphology, migration, and proliferation. the influence of a self-assembled scaffold formed from an ionic complementary peptide modified with biorecognition motifs on the cell morphology, spreading, and migration was investigated using clsm. the results indicated that the designer peptides modified with cell adhesion motif from osteopontin and signaling motif from osteogenic signaling peptide promoted excellent growth and proliferation of osteoblasts. scanning probe microscopies, especially the atomic force microscopy (afm), have been widely used to investigate the geometry of the self-assembled nanostructures, to measure their conductivity, and to determine the young's modulus and thermal stability of the structures under dry conditions. the afm contains a probe attached to a flexible cantilever, and as the probe moves over the sample at a preset rate, the force of interactions between the probe tip and the sample surface is measured, and the topography of the sample is constructed. the deflections in the cantilever are recorded by monitoring the reflection of a laser beam focused on the cantilever and recorded through a photosensitive photodiode. this technique offers atomic level resolution and can be a very valuable tool in research on self-assembled structures. the probe tip, generally in the range of 10 nm, can be conducting or nonconducting and can be functionalized to investigate specific interactions. the material of the probe and its geometry are vital in determining its performance. the data acquisition in afm can be made in the contact mode or noncontact mode or tapping mode. one of the challenges involved in using afm technique is to study peptide self-assembly in solution as it requires sufficient adhesion with the substrate. generally, afm had been extensively employed to study the morphology of the aggregates formed by the self-assembly of peptides. chaudhary et al. had investigated the propensity of two sequences derived from the amyloid tau protein ac-vqivyk-amide and ac-qivyk-amide to form beta-sheets in the presence of different solvents using afm [106] . the results revealed that the ac-vqivyk-amide existed both as alpha helices and beta-sheets and the nature of the solvent was a key determinant of the form in which the peptide aggregates existed. the formation of the supramolecular assemblies by the peptide can also be monitored in a time-dependent manner using the afm probe. time-lapse liquid imaging of amyloid fibrils has been employed for kinetic studies on the rate of formation as well as morphological changes introduced in the amyloid peptide during the aggregation process under various self-assembling conditions [107] . for the determination of young's modulus, the afm tip is positioned on the top of the structure and pressed. from the force-distance curves, the young's modulus can be directly derived using the theoretical model proposed by niu et al. [108] . however, this model has a limitation since it depends on the type of structure that can be assumed. for example, if it is a hollow structure rather than a solid, then the young's modulus calculated using this model will exhibit significant deviations from the actual value. knowles et al. have used another approach to understand the rigidity and mechanical strength of the self-assembled amyloid fibrils on mica substrate [109] . the topography of more than 900 fibrils was imaged using afm and the shape fluctuations were used to compute the bending rigidity (c b ) of the fibrils. the cross-sectional moments of inertia (i) were computed for each fibril based on their height measured using afm. the young's modulus (y) was then computed as y ¼ c b /i. these values range between 2 and 14 gpa for most protein fibrils. the young's modulus for the completely self-assembled amyloid fibrils falls in the range 13 and 42 gpa. the elastic modulus of the peptide assemblies can be further dissected into contributions from the backbone as well as the side chains, i.e. y ¼ y bb + y sc where y bb and y sc are contributions from the peptide backbone and side chains, respectively. the computed results suggest that the contribution of the backbone interactions towards the elastic modulus is more than twice that of the side chains. in the case of amyloid fibrils, the contribution of y bb is about 74 %. it is also postulated that peptide structures with moduli greater than 22 gpa have significant contributions from the involvement of side chains in hydrogen bonding. in the absence of significant intermolecular hydrogen bonding in the peptide structures, the surface tension arising due to the hydrophobic and hydrophilic residues can also be employed to determine the young's modulus using the relation y ¼ 2g/h where g is the surface tension and h is the inter-sheet spacing with values in the range of 8 and 12 å . for the observation of thermal stability of the nanostructures under dry conditions, the afm tip is positioned above the structures and the position of the tip is monitored with increase in temperature. at a particular temperature, as the structure degenerates, the tip will move downward which gives an indication of the maximum temperature beyond which the nanostructure will lose its stability. transthyretin fibrils have been examined for their stability after prolonged exposure to high temperatures using afm, and it was found that the thermal stability of the pre-fibrillar aggregates was poor when compared to the fibrillar assemblies [110] . electron microscopic techniques, which include scanning and transmission electron microscopy, are commonly employed tools for imaging self-assembled structures. focused ion beam milling techniques were also recently employed to characterize the nanostructures. scanning electron microscopy (sem) is usually used to determine the geometry of the nanostructure. however, the presence of any defects or cavities in the structure can be better visualized using transmission electron microscopy (tem) where high-energy electrons pass through the nanostructures and the final image is reconstructed by mapping the intensities of electrons from each point in the sample. the more conducting regions in the sample will therefore appear dark when compared with regions with some resistance to the passage of electrons. the imaging is usually done in ultrahigh vacuum of the order of 10 -9 pa. the main advantages of electron microscopy techniques when employed for visualizing the morphology of the peptide structures are ease of implementation, high magnification, resolution, and its ability to image a range of dimensions ranging from sub-nanometric to micrometric scales. these prospects are possible due to the smaller wavelength of electrons employed when compared to the visible light. the scanning electron microscopic technique when applied to nonconducting samples such as peptide nanostructures requires a thin coating of an inert metal such as platinum or gold to enable generation of the image. otherwise, the electrons will remain on the surface of the sample making the visualization of the finer structures on the sample impossible. in the case of transmission electron microscopy, there is a restriction in the thickness of the sample that can be imaged. samples less than 0.1 mm alone can be imaged using transmission electron microscopy, as thicker samples will not permit transmission of the electrons. it is not advisable to use accelerating voltages beyond 10 kv in scanning electron microscopy for analyzing peptide nanostructures. similarly, in transmission electron microscopy, very high voltages will lead to damage of the peptide structures. apart from giving information on the morphology of the aggregates, the dimensions of the individual self-assembled structures can also be obtained from the electron microscopy techniques. the thermal stability of the structure can also be investigated using sem where after exposing the nanostructure to particular temperature, the structures can be imaged to observe any deformations postexposure to high temperature. the strength of the structure can be determined using sem combined with fib source (fib -focused ion beam). the nanostructure is placed inside fib sem and the time taken to mill the sample is analyzed [111] . by comparing the time with the standard materials, the stability of the structure can be determined. the incorporation of metallic compounds in the peptide assemblies can be imaged using tem. for instance, tem was employed to determine the presence of cuo within the nanotubes due to the enhanced contrast provided by the metallic compounds [112] . recently modified ff peptide nanotubes were used for the determination of the neurotransmitter dopamine. the ff nanotubes were modified with cyclic-tetrameric copper (ii) species containing the ligand (4-imidazolyl)-ethylene-2-amino-1-ethylpyridine [cu 4 (apyhist) 4 ] 4+ (apyhist refers to the ligand 2-(1h-imidazol-4-yl)-n-(1-(pyridin-2-yl)ethylidene)ethanamine) in nafion membrane on a glass carbon electrode. the morphology of the modified tubes imaged using scanning electron microscopy revealed tubular structures of thickness around 350-500 nm. the deposition of the nafion membrane on the nanotubes was also clearly distinguished [113] . circular dichroism (cd) is a technique that is applied to optically active chiral molecules such as proteins and peptides. it is based on the principle of differential absorption of right and left circularly polarized light by the chiral molecule. cd spectroscopy is an invaluable tool to identify the secondary structures adopted by a peptide during the self-assembly process. the exact location of the alpha helices or beta-sheets or random coils can be identified by this technique, and it provides information on the structural transformations that can occur during the self-assembly process under different conditions. hauser et al. have used this technique to show that the self-assembly process proceeds through structural transition that may occur in three possible steps based on the peptide concentration [114] . the peptide monomers interact via antiparallel pairing which is followed by a structural transition to a-helical conformation. the peptide pairs assemble to form fibers and condense to form fibrils. the assembly of the peptide monomers serves as the nucleation step, which then proceeds to form fibrils via nucleation-dependent polymerization mechanism. the assembly of peptide monomers, however, requires a transition from random coil to a-helical conformation. though it is reported that short peptides of 3-6 amino acids cannot form a-helical conformation, it is indeed possible above a threshold concentration. the cd spectra also demonstrated that at low concentrations, the peptides were stable up to 90 c and changed its random coiled structure as the temperature is increased from 25 c to 90 c. this change was reversed on cooling. however, once the fibril is formed, the peptide ensembles adopt b-turn structures, and no reversal in conformation is observed upon changing the temperature. circular dichroism has also been widely used to study the kinetics involved in the formation of a peptide network. it was used to show that the beta-sheet structures progressively increase with concomitant reduction in helical coils in peptides with a propensity to form fibers [114] . zhang et al. had reported that the ionic complementary peptide eak16 formed a macroscopic membranous structure due to extensive beta-sheet formation [56] . the membrane formation propensity was retarded in the dodecapeptide eak12, while the octapeptide eak8 did not form membranous structure. investigations with cd spectroscopy revealed that the eak16 formed beta-sheets extensively, while eak 12 had both alpha helix and beta-sheets and eak8 had only random coils. similarly cd spectroscopic studies on the self-assembly of kfe8 (fkfefkfe) revealed the presence of left-handed double helical beta-sheets that could represent a new category of molecular materials. the properties of the peptide bond can be studied using x-rays. linus pauling and robert corey were the first to report the length of c-n bond in the peptide link. they also found that the peptide bond is planar, i.e. all the four atoms in the peptide bond are located in the same plane and the a-carbon atoms attached to the c and n are in trans conformation. the structural and functional relationships in the fibrous protein in wool were established using x-ray diffraction patterns by william astbury [115] . x-ray diffraction has been now employed to determine the crystal structure of any newly synthesized peptide. it has also been used to calculate the bond distances and bond angles between the moieties in the peptide. based on the torsion angle measurements, it is also possible to predict the secondary structure conformation adopted by the peptide. moreover, the forces that stabilize the crystal structure such as van der waals and hydrogen bonding interactions can also be predicted. x-ray diffraction technique is also employed to determine the ultrastructural organization found in self-assembled peptide structures. nanofibrillar arrangement results in characteristic diffraction patterns that reveal the presence of cross b-sheet structures. the meridional and equatorial reflections have been used to identify the amyloid structure. the spacing between the hydrogen-bonded b-strands results in meridional reflection at 4.7-4.8 å , and the distance between the b-sheets contributes to an equatorial reflection at 10 and 11 å [116] . the main challenge in employing x-ray diffraction techniques is that it is difficult to obtain pure crystals of many self-assembled structures. the x-ray data is usually obtained using a beam wavelength of 0.975 å and an extremely small beam size of about 5 mm. generally, the crystals need to be cooled to about 100 k for data recording. localized radiation damage to the crystals could be avoided by illuminating the peptide crystals at different locations. due to the high degree of complexity involved in understanding the mechanism of self-assembly, various theoretical and computational methods have also been employed. these techniques not only help in understanding the mechanism but also to design the new sequences with the selected properties for nanobiotechnological applications. in particular, molecular dynamic simulations have been used to monitor the dynamics and investigate the influence of mutations and solvent effects in the conformational transition from alpha helices into beta-sheet structures [117] . various algorithms and theories have been developed to investigate the properties of complex biomolecular systems at different levels. due to the high degree of complexity involved along with the small time scales, coarsegrained models were used to follow the actual process [118] . however, in this model, fine atomic details are neglected and only relevant degrees of freedom of peptide molecule are retained. activation relaxation technique is a subcategory of the coarse-grained model, where the interactions among several peptide chains were simulated ab initio with no bias in original orientation and conformation. molecular dynamics studies have now been employed to address peptide self-assembly [119] . these simulations have certain advantages such as ability to mimic the actual self-assembly of the peptide residues, reveal the structural information at an atomic level of the peptide, and provide a dynamic molecular model at atomic level of ordered assembly. however, there are certain limitations associated with this technique, too, such as a limited resolution, strong dependency of the quality of predictions on the size of the peptide, and the limited number of peptide residues for which such predictions could be made. several computational approaches have been used to predict the aggregation propensity of the proteins. for example, a computer program named tango considers the secondary structure and the desolvation penalty of the residues for calculating the aggregation propensity [120] . all the techniques discussed thus far are used to characterize the nanostructures in dry conditions. however, stability of the structures differs when they are analyzed in wet conditions. to determine the stability of the nanostructures in wet conditions, they are submerged in aqueous solution, and the concentration of monomers is monitored with time using high-performance liquid chromatography (hplc). the increase in the concentration of monomers with time is an indication that the nanostructures are dissolving in the medium and are, therefore, not stable. high-performance liquid chromatography has also been employed to identify impurities associated with the peptide after synthesis [121] . microrheometry technique is widely used to perform measurement on weak hydrogels without affecting their structural components. the measurements are very fast, and the experiments are not affected by external factors as they carried out in a closed chamber. recently, multiple particle-tracking microrheology experiments were used to follow the hydrogel formation by the peptide kfe8 [122] . fourier transform infrared spectroscopy (ftir) analysis reveals the presence of parallel or antiparallel beta-sheets and nature of hydrogen bonds in the self-assembled structures. differential scanning calorimetry (dsc) and thermogravimetric analysis (tga) are used to determine the effect of temperature on the self-assembled structures. while dsc gives information on the phase transition temperatures of the peptide assembly, tga provides information on the degradation profile of the assemblies. crystallographic studies have also been carried out to understand the mechanism of self-organization. biocompatibility and immunogenicity of the selfassembled peptide structures have to be evaluated before their use in biological systems. both in vitro and in vivo studies need to be carried out to evaluate the biocompatibility of a peptide assembly. the self-assembled structure fabricated using the fmoc-diphenylalanine peptide was used as a scaffold to grow chinese hamster ovary (cho) cells. the cell viability analyzed using mtt assay showed that 90 % of the cells were viable, suggesting that the peptide scaffold is biocompatible. more in-depth biocompatibility and immunogenicity assessment is however necessary to eliminate any potential risk of using these structures for biomedical applications [123] . the unique reproducible structures obtained through self-assembly of peptide sequences have many interesting applications in biological and nonbiological fields. figure 8 .8 depicts multiple applications that can arise from a cyclic peptide. a few of them are highlighted in the following sections. peptide systems that form nanofibrils similar to those formed by the amyloid beta peptide have been investigated extensively to understand the mechanism of formation of amyloid fibrils. amyloid fibril formation has been implicated in a wide range of degenerative diseases like alzheimer's, parkinson's, type ii diabetes, and other prion-related diseases [124] [125] [126] [127] . the switch peptides have also been employed to find information about the interactions between the various proteins involved in the pathology of protein conformation diseases like scrapie, kuru, huntington's, parkinson's, and alzheimer's disease [128, 129] . amyloid fibrils are formed by various peptides such as the full-length human islet amyloid polypeptide (hiapp), nfgsvq peptide fragment from medin, and ff peptide from alzheimer's amyloid beta peptide. nfgail a hexapeptide fragment from islet amyloid polypeptide is reported to form well-ordered amyloid fibrils which exactly mimics those formed by the parent peptide [130] . two active amyloidogenic peptides, namely, nflvh fragment of hiapp and nfgsvq fragment derived from aortic medial amyloid, also formed fibrils. another peptide from the human calcitonin, namely, nh 2 -dfnkf-cooh, is also reported to form amyloid fibrils similar to those formed by the parent protein [56] . a short truncated tetrapeptide, namely, nh 2 -dfnk-cooh, also formed fibrils, which clearly shows there is no correlation between hydrophobicity and amyloidogenic potential since most of the short peptides are relatively hydrophilic. these results were further supported by johansson et al., who studied charged tetrapeptides and proved hydrophobicity is not sufficient for fibril formation [131] . peptide legos (rada, eak), peptide amphiphiles, bolaamphiphiles, peptide conjugates, ionic self-complementary peptides, and long-acting gonadotropin-releasing hormone have all been reported to self-assemble into amyloid fibril structure. many peptides derived from the alzheimer's amyloid beta peptide also been shown to form fibrils. these include aaklvff, klvffae, ßaßaklvff, yyklvffc, ffklvff-peg, ffklvff, ac-klvffae-nh 2 , ff, and yyklvff-peg [132] [133] [134] [135] . it has been concluded that alternating binary patterns and the peptides with high beta-sheet propensity are prone to form amyloid structures. gazit and coworkers have identified that aromatic amino acids play an important role in amyloid fibril formation through p-p stacking interactions [136] . custom-made peptides used as model systems should possess strong electrostatic binding with the negatively charged lipid membranes and should exhibit structural transition from random coil to beta-sheet on binding to lipid membranes which initiates the association and the formation of oligomers and larger aggregates. apart from utilizing the self-assembling peptides to understand the pathological mechanism, it is also used to understand the functions and mechanisms of assembly of proteins like collagen. tobacco mosaic virus (tmv) is also a form of supramolecular structure assembled from a single strand of mrna along with many copies of identical coat proteins, which organize to form rod-like shape. this tmv has been used by schlick et al. for the construction of nanoscale materials without disrupting its self-assembly [137] . peptide molecules also have the ability to self-organize at the air-water interface, which are widely used for mineralization studies because of its resemblance to insoluble proteins found in nature. self-assembling peptides have gained considerable interest in the field of tissue engineering because functional tissue recovery has been observed in brain and heart lesions [138, 139] . one common example is the incorporation of cell adhesion motif rgd in the peptide sequence, which improves the cell adhesion onto the self-assembled structures formed by peptide amphiphiles. collagen-mimetic peptide amphiphiles, which self-assemble into nanofibers that exactly mimic the structural and biological properties of the native collagen, have been widely used in tissue regeneration as natural collagen is immunogenic and difficult to process [140] . molecular lego peptides, such as rad 16-i and eak 16, have been used as scaffolds for neurite outgrowth, hepatocyte regeneration, etc. [146] . chondrocytes encapsulated in a peptide scaffold using a self-assembled peptide with the sequence (ac-kldlkldlkldl-nh 2 ) exhibited excellent phenotype and secreted its own growth factors within 4 weeks of culture [147] . peptide nanovesicles have been employed as drug carriers and it is believed that these nanovesicles enter the cells via endocytosis mechanism and thus can deliver drugs, genes, etc. [95] . hydrogelating self-assembling fibers (hsafs) designed by woolfson and group using coiled-coil assemblies had limited use as a drug delivery system due to the limitation of rapid drug release. however, this was overcome by incorporating an anionic polyelectrolyte in the cationic peptide [148] . ghosh et al. designed a smart self-assembling peptide amphiphile that transforms from a linear or spherical form to fibrous form upon altering the ph for drug delivery and in vivo imaging applications [149] . the nanotubes formed by cyclic peptides comprising d-and l-amino acids serve as ion channels and form pores in the membranes leading to disruption of the cell architecture. as d-amino acids are taken up preferentially by microbes, these systems can function as effective antimicrobial agents which kill the microorganisms through formation of pores in the cell membrane, thereby causing osmotic collapse [150] . mackay et al. have created a chimeric polypeptide consisting of an elastin-like polypeptide (elp) fragment and a short cysteine-rich fragment for the treatment of cancer [151] . the drug conjugated with the cysteine residue drives the self-assembly that finally forms a drug-rich core and a hydrophilic peptide corona. instead of a drug, the self-assembly can also be triggered by linking the hydrophobic cholesterol moieties with hydrophilic cell penetrating peptides consisting of six arginine residues. these peptide nanoparticles have antimicrobial properties and were shown to effectively terminate the bacterial growth in the infected brains of the rabbits. beta-sheet-rich peptide nanofibers functionalized with b-cell and t-cell epitopes have been developed for immunization [152] . these functionalized nanofibers developed antibodies in mice when injected with saline, and the levels were comparable with those injected with complete freund's adjuvant. protection against the beta-sheet-rich peptide nanofibers lasted for a year and the antibody response is t-cell dependent. recently, self-assembling peptide/protein nanoparticles have been used as antigen display systems for the development of vaccines. for example, a fragment of the surface protein of severe acute respiratory syndrome coronavirus (sars-cov) was incorporated in a self-assembling peptide nanofiber in the native trimeric coiled conformation [153] . antibody formation was elicited when these peptide structures were injected into the mice, and the antibodies were conformation specific as determined by qualitative enzyme-linked immunosorbent assay. peptide nanofibers have been extensively investigated as the next-generation biosensors where they are used both as a fabrication material and also as a component in the final system (biofet) [86] . nanotubes coated with proteins, nanocrystals, and metalloporphyrins by hydrogen bonding have been employed as chemical sensors. these nanotubes also served to improve the catalytic activity of the enzymes like lipase. apart from using ff nanotubes as a template for the fabrication of nanowires, they have also been used for biosensing where ff nanotubes are deposited on the surface of screen-printed graphite and gold electrodes for improving the sensitivity. it is also reported that these electrodes exhibit greater sensitivity compared to those electrodes modified with carbon nanotubes. the possible reason may be that the ff nanotubes increase the functional surface area of the electrode. electrical and magnetic fields have been used to align ff nanotubes. apart from this, patterning of the ff tubes has been carried out using inkjet technology, machined by thermomechanical lithography via atomic force microscopy, manipulated and immobilized using dielectrophoresis, and arranged on the surfaces by low electron irradiation [31] . nanotubes are also used in the detection of pathogens, neurotoxins, glucose, ethanol, and hydrogen peroxide and as an immunosensor [72] . peptide nanofibers have been reported for the detection of copper, dopamine, yersinia pestis, glucose, etc. [141, [154] [155] (fig. 8.9 ). amyloid-forming peptides are used in the field of nanoelectronics as nanowires. for example, ff nanotubes are used as a template for silver nanowires of diameter of approximately 20 nm. switch peptides find application in molecular electronics by serving as a nanoswitch [142] . ryu et al. developed photoluminescent peptide nanotubes by incorporating luminescent complexes composed of photosensitizers like salicylic acid. kasotakis et al. employed self-assembled peptides as a scaffold for the introduction of metal-binding residues at specific locations within the structure [143] . an octapeptide from the fiber protein of adenovirus was used to design cysteine-containing octapeptides that can bind to silver, gold, and platinum nanoparticles. these metal-decorated fibers were employed in photodynamic therapy and also used in the development of surface-enhanced raman-scattering biosensors for detecting dna. lipid-like peptides find application in solubilizing, stabilizing, and crystallizing membrane proteins, used for drug formulations and also as model systems for studying protein conformational diseases [144] . velcro peptides have been mainly used to study cell-cell communication and cell behavior [145] . ff nanotubes are used as an etching mask for the fabrication of silicon nanowires. it reduces fabrication time, cost, and use of aggressive chemicals. it is also possible to scale up these arrays of ff nanotubes by vapor deposition methods. self-assembling peptide nanostructures have also been used as photosynthetic devices, and the peptide ac-klvffae-nh 2 is reported to form nanotubes. precise ordering of strong chromophores along the inner and outer walls of the nanotubes enables utilization of this peptide structure as nanoscale antennas and photosynthetic device [156] . the peptide nanofibers can also serve as a template for the growth of inorganic materials such as silver, gold, platinum, cobalt, nickel, and various semiconducting materials (fig. 8.10 ). an in-depth understanding of the molecular self-assembling mechanism of peptides and various stabilizing forces associated with the overall stability of the nanostructures formed by them is essential to design novel applications using these peptides. various classes of self-assembling peptides have been developed that have led to emergence of novel applications in the fields of tissue engineering, drug delivery, electronics, etc. different characterization tools have been designed to decipher the structural and functional aspects of the self-assembled peptide structures. the field of self-assembly continues to expand and has opened up new vistas for further research. synthesis of a tubular polymer from threaded cyclodextrins self-assembly of peptide-based colloids containing lipophilic nanocrystals transition of cationic dipeptide nanotubes into vesicles and oligonucleotide delivery novel electrochemical biosensing platform using self-assembled peptide nanotubes self-assembly and application of diphenylalanine based nanostructures peptide and protein building blocks for synthetic biology: from programming biomolecules to self-organized biomolecular systems emerging 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encapsulated in a functionalized self-assembling peptide hydrogel for brain tissue engineering fine-tuning the ph trigger of self-assembly artificial transmembrane ion channels from self-assembling peptide nanotubes self-assembling chimeric polypeptidedoxorubicin conjugate nanoparticles that abolish tumours after a single injection a novel vaccine using nanoparticle platform to present immunogenic m2e against avian influenza infection peptide nanoparticles as novel immunogens: design and analysis of a prototypic severe acute respiratory syndrome vaccine development of an electrochemical metal-ion biosensor using self-assembled peptide nanofibrils self-assembled diphenylalanine nanowires for cellular studies and sensor applications an auto-biotinylated bifunctional protein nanowire for ultra-sensitive molecular biosensing remote electronic control of dna hybridization through inductive coupling to an attached metal nanocrystal antenna design of metal-binding sites onto self-assembled peptide fibrils self-assembling peptide-based nanostructures for regenerative medicine self-assembly of collagen-mimetic peptide amphiphiles into biofunctional nanofiber self-assembling functionalized nanopeptides for immediate hemostasis and accelerative liver tissue regeneration key: cord-338007-fa4i981h authors: coyne, lisa w.; gould, evelyn r.; grimaldi, mikala; wilson, kelly g.; baffuto, gabriel; biglan, anthony title: first things first: parent psychological flexibility and self-compassion during covid-19 date: 2020-05-06 journal: behav anal pract doi: 10.1007/s40617-020-00435-w sha: doc_id: 338007 cord_uid: fa4i981h the covid-19 pandemic has brought about significant stress and anxiety for many parents around the world. psychological flexibility and self-care are fundamental aspects of psychological health. for parents, shaping these processes may help promote family nurturance, support children’s prosocial behavior, and provide effective and consistent use of evidence-based parenting “kernels.” the goal of this article is to provide practitioners with evidence-based tools that will support psychological flexibility, self-care, and positive parenting behaviors in caregivers during covid-19 and beyond. placed under conditions such that they are more vulnerable to becoming sick (valentino-devries, lu, & dance, 2020) . in addition, whereas 9 out of 10 americans are under a shelterin-place order, many first-line health care workers are unable to stay home. consider that these parents may be returning home at the end of the day, unable to hug their children due to contamination fears, burdened by working with the very ill without adequate medical supplies, and perhaps traumatized by the necessity to make difficult treatment decisions. the covid-19 pandemic has confronted many parents with difficult choices. parents may be dealing with the stress of going back and forth to work and the potential contamination of their homes. some may be dealing with increased demands of homeschooling their children while still trying to meet their own employment requirements. some may have elderly parents whom they need to care for and ensure the safety of. for parents of children with developmental delays, chronic emotional or behavioral difficulties, or other health challenges, the demands are further increased. as demands and parent stress increase and resources dwindle, children may also be placed in increased proximity of domestic abuse (tolan, 2020) . in sum, parents in the united states and beyond are experiencing a collision of roles-parent, partner, employee, business owner, employer, sibling, caretaker, friend, child, teacher, and so on. they may be faced with fear and uncertainty about the future and how to keep their families safe, while managing this collision of roles, responsibilities, and expectations. many families are distancing not only from other people but also from everything that is familiar. as practitioners, how do we continue to provide meaningful and effective services when we and the families we serve are faced with intractable, chronic stress and uncertainty that is beyond our control? this can feel like an overwhelming and even impossible task. behavior analysts are generally well equipped with evidence-based behavioral intervention strategies for supporting parents; however, it may also be important to consider the broader context of parent behavior, such as the role of private events (including "psychological distress") and the family's cultural, socioeconomic, and historical context. families may need assistance to ensure that their basic needs are met, including food, shelter, clothing, safety, health care, and financial support, before behavior analysts provide other kinds of support. practitioners will need more than their standard toolbox of behavioral parenting strategies: technical skills must be balanced with fluency in collaboration, compassionate care, therapeutic alliance, and self-care skills (leblanc, taylor, & marchese, 2019; taylor, leblanc, & nosik, 2019) . on an airplane, when there is an emergency, parents are told to put on their own oxygen masks first so that they can effectively support their children and keep them safe. in the time of this pandemic, practitioners must thus teach parents how to care for themselves if they are to expand their ability to nurture their children through adversity. similarly, if practitioners are to effectively support other families, they will also need tools for managing their own distress and buffer against the effects of burnout. the goal of this article is thus to provide immediate tools that strengthen both parent and practitioner resiliency and flexibility in the context of covid-19. such tools may also support families beyond present challenges by creating longer term resilience. specifically, we will describe how to support parents' psychological flexibility and self-care. psychological flexibility refers to the ability to recognize and adapt to situational demands, to remain aware and open to the present moment such that one can recognize and shift behavior strategies as required by situational demands, and to engage in actions that are congruent with one's deeply held values (hayes, strosahl, & wilson, 2012; kashdan & rottenberg, 2010) . self-care, as defined by the world health organization, refers to the practice of taking action to preserve or improve one's own health, especially during periods of stress, or "the ability of individuals, families and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a healthcare provider" (world health organization, regional office for south-east asia, 2014: p. 15). it is our contention that supporting psychological flexibility (burke & moore, 2015; da paz & wallander, 2017; hartley, dorstyn, & due, 2019; irwin, jesmont, & basu, 2019; moyer et al., 2018; williams, ciarrochi, & heaven, 2012) and self-compassion (gouveia, carona, canavarro, & moreira, 2016; neff & faso, 2014) in parents is foundational to bolstering and maintaining psychological well-being in families and that providing parents with tools in these domains is to empower them to better cope with conditions of stress and uncertainty. the tools outlined in what follows are components of acceptance and commitment therapy (act; hayes et al., 1999 hayes et al., , 2012 and can be grouped into three domains: (a) mindfulness and acceptance, (b) committed and valued action, and (c) self-compassion. in behavioral terms, mindfulness and acceptance processes involve paying purposeful attention to the present moment, allowing or making space for unwanted thoughts and emotions, and relinquishing attachment to thoughts as literal truths, where that is helpful. commitment and valued action involve making a promise to oneself about something that really matters and following through with that commitment. self-compassion involves self-kindness, awareness of our common humanity, and willingness to acknowledge difficult thoughts and emotions, without attachment (neff, 2012) . given the urgent need to equip behavioral practitioners with resources for parents, we have avoided more academic language in favor of a more practical approach: we have attempted to describe these tools in such a way that is widely accessible and that may be put into practice immediately. for example, we intentionally use lay language such as "thoughts and feelings" instead of "private events," "taking our minds literally" instead of "excessively rigid rule following with respect to private verbal stimuli," and "coercion" instead of "excessive reliance on negative reinforcement and punishment." the principles behind these strategies are evidence based; however, many of their particulars have not been investigated within the context of a pandemic. nonetheless, they are firmly grounded in behavioral principles. we have intentionally left the fine-grained behavioral interpretations of act procedures out of this article, but we refer the reader to chapter 20 of cooper, heron, and heward (2020) for behavioral conceptual analyses of act. furthermore, the strategies in this article are not offered as alternatives to more mainstream applied behavior-analytic procedures but as supplements to them. overall, the approaches in this article seek to increase access to positive reinforcement and reduce levels of aversive control in the lives of parents and children. we do not need more evidence that an abundance of positive reinforcement and reductions in aversive control are beneficial to those we work with (and all of humanity, for that matter). before behavior analysts provide parents with strategies to support their psychological flexibility, it is worth articulating some "travel guidelines" in preparation for their journey. these are not the "what to do" of self-care but rather "in what way" self-care should be approached. context matters, and as such, these pointers that follow may serve as reminders that can guide continued practice and generalization. we have included them as hashtags to underscore that broad dissemination via social media is possible, and may be an effective way to encourage the use of these practices through social networking. #smallthingsmatter "small things matter" is an important principle for action and informs the study of "kernels," or fundamental units of behavioral influence that appear to underlie effective prevention and treatment for children, adults, and families (embry & biglan, 2008) . larger long-term goals such as "getting in shape," "eating a healthy diet," and "being a better parent" can be daunting. taking the stairs instead of the elevator, eating the apple instead of the cookie, and stopping to kiss a child on the head are smaller steps that may be more attainable. there are lots of data that show big impacts from small changes, such as tiny amounts of running, small reductions in sugar intake, small nurturing social interactions, and just a little more sleep. oftentimes, people may attempt to control things that are beyond their control. thus, it is important to help parents focus their efforts on things that they can influence within the system of the family. with the understanding that everything interacts, this focus should aim toward those areas that may have the most impact. for example, sleep deprivation can have a troubling impact on appetite, social interactions, emotional responses, and immune function (furman et al., 2019) . a little bit of improvement in a single thing like sleep can also make a positive impact on these same areas. parents do not have to lift it all at once. #patternsmatter one of the obstacles to behavior change is that people become too focused on perfection when most often it is the pattern that matters. a doughnut on occasion has little health impact. doughnuts all day, every day, on the other hand, may be problematic. it is possible that parents may be insensitive to the long-term effects of unhelpful patterns due to more immediate contingencies dominating their behavior: consider gerald patterson's work on coercion (patterson, 1982) . patterson illustrated how parents quickly get pulled into coercive cycles with their children, due to the powerful (immediate) effects of punishment and negative reinforcement on parent and child behavior, despite long-term negative effects on both parents and children. mindful awareness of triggers to unhelpful patterns opens a space in which parents can choose to do something different, and potentially more helpful, for themselves and their children. we may encourage parents to become aware of their behavioral patterns and to notice how those patterns are working for them, both in the short and long term. parents may then have the space to create new patterns of flexible, workable parenting behaviors over time. #meaningmatters entire psychologies have been constructed around meaning making (e.g., frankl, 1985) . part of the reason small things matter lies not in the thing itself, but rather in the meaning of the thing. when you take a moment with a child, and that moment becomes a pattern of such moments, it says something to the child. it says, "you are worth pausing over. you are interesting. time with you is valuable. you matter." even if you are wildly busy with work or keeping house and home together, these small pauses and small hesitations speak volumes. the moments of our lives go by in an instant, but what lasts is the stories we tell: "even when things got scary, i knew i was loved." #wearestrongertogether human beings survived and multiplied on the planet because we are super-cooperators (or "eusocial"; wilson & wilson, 2007) . this sensibility is in every cultural tradition, though modern times have deemphasized it with the idea that we should be able to do things "on our own." we encourage parents (and practitioners) to seek and to offer help. two are stronger than one. we encourage parents to care for themselves in their "out-loud voice" and to team up with a friend, even online. this breaks some cultural taboos against seeking help, but if parents adopt it, they give tacit permission for help seeking and partnership in their social network. join groups, make groups, and foster, enrich, and appreciate the connections you already have. as an incredible bonus, our children learn an enormous amount from observing us. when we take time to care for ourselves, our children see that and learn. #selfcareaslove it may be unhelpful to frame parent self-care as an addition to their to-do lists. that list is already too long, and parents are already challenged and accountable in a thousand ways. instead, it may be important to consider self-care as a quality of action: it can be an act of love and kindness. to help parents see this, we suggest encouraging perspective-taking. it may be useful to encourage parents to reflect on an act of love toward them by others. encourage them to pause and recall those times, that person, and their demeanor. essentially, encourage them to look at themselves through the eyes of a loved one. that is the quality of action we are seeking in self-care. small practices to support patterns of psychological flexibility and self-care with the aforementioned qualities in mind, we describe specific tools in the following sections that can equally be adopted by practitioners to support their own well-being and resilience as they strive to respond compassionately and effectively to families in distress. indeed, we invite practitioners to "put on their own oxygen masks first" alongside the parents they are working with. we present these small, actionable steps nestled under the three broad domains mentioned previously: mindfulness and acceptance practices, committed and valued action, and self-compassion practices to support selfcare. step 1: mindfulness and acceptance present-moment awareness enlist parents in a practice of gentle, curious, and open attention on purpose several times during the day, just for a few moments at a time, such that they strengthen this skill. start small and make it doable. embed this practice in activities of daily living-activities that parents are already doing, such as making breakfast, taking a shower, walking, chopping vegetables, folding laundry, and so on-so that it constitutes no extra effort. to introduce the practice, you may ask parents this question: over the course of your day, what percentage of the time are you right here, right now, versus "time traveling"? that is, worrying about the future and what might happen or ruminating about the past-about things you should have done or didn't do? most people notice that they are actually in the present moment for just a modicum of time, and it is an interesting experience to notice that "the lights are on, and no one is home" for much of the day, so to speak. encourage parents to pay attention on purpose briefly, at various points of the day, while engaged in daily activities. it is helpful to simply bring your awareness gently to the present by slowing down-and either noticing what you are experiencing with your five senses, or, alternately, pausingand hold a space in which you can check in with yourself with these simple questions: how am i doing? what is it that i most need right now? it is also helpful to encourage parents to pay purposeful attention to even small things that are meaningful, and to practice bringing awareness to things that they are grateful for-for example, drinking a cup of coffee, feeling the softness and warmth of the bed in the morning, kissing their child's forehead at bedtime, or a quiet moment before sleep. acceptance a necessary corollary to practicing presentmoment awareness is acceptance, which does not mean tolerance, endurance, or "getting used to" stressors. it refers to an awareness of, and openness to, the inevitable sadness and stress that are part of life, and the flip side of joy, without struggle. one context in which nonacceptance can show up for parents is when they feel they have made mistakes, or failed, in child-rearing duties. this tends to engage their critical minds and evokes thoughts like "you are not enough. you are a terrible parent. you are a hot mess compared to other parents." it also evokes a struggle to "feel better," which can compound and intensify the situation, thus occupying so much of parents' mental bandwidth that they have none left to be truly present and connected with their children. in your meetings with parents, take some time to make a space for them to voice these thoughts, and normalize them. resist the urge to immediately jump in to "fix" it or problem-solve it away. instead, we might nonjudgmentally let a parent know that it is okay not to be okay: this is a struggle for all of ussometimes, me too. see if you can make a space to notice those thoughts and feelings; see if you can soften yourself around them, breathe into them. simply allowing parents to be vulnerable-and perhaps sharing a tiny glimpse of your own vulnerability-may help them carry these difficult experiences more gently and with less effort. defusing from painful thoughts evolution has conferred to humans the remarkable ability to learn indirectly, without training, through language. for example, we can avoid danger when someone gives us the rule "don't touch that; it's hot" or thoughts such as "if you don't organize your child's homeschooling properly, you will ruin them!" our ability to treat our thoughts as real things, called fusion, has given us marvelous flexibility in adapting to our changing environment; however, it can also evoke rigid and inflexible patterns of behavior if we always treat thoughts as literal truths. this can create challenges when parents experience triggering thoughts about current stressors. thus, a simple practice that you can teach parents is to notice thoughts for what they areimpermanent mental phenomena that are sometimes useful and sometimes not. encourage parents to do the following: if you are feeling stressed, take a few moments to slow yourself down and notice the process of your thinking. you may notice your mind is pulling you this way and that or going a hundred miles an hour. see if you can bring your curiosity to your thoughts-slow down each one, imagine stretching it out like taffy, and add to it the stem "i'm noticing the thought . . ." or "my mind is giving me the thought . . ." take a few moments to do this "thought spotting" exercise, and as one thought passes, be curious about what the next thought is that might arise. practice this a few times throughout the day, when you think of it, and notice anything about this experience that surprises you or that you didn't expect. in essence, this practice supports mindful awareness of, and detachment from, one's thoughts such that parents are better able to notice and be influenced by the relevant cues in their environments. perspective-taking humans often have a difficult time observing their own behavior, especially in real time. we are so often in our heads that it may be a challenge to track or notice the effects of our behavior on others. it is this insensitivity that factors into the intransigence of our rigid and unhelpful patterns of behavior, such as coercion. thus, practitioners may encourage parents, during calm moments, to reflect back-for example, on interactions with their children-as follows: when you have a few moments to yourself, pause and see if you can imagine yourself as you were earlier today, when you felt like you were struggling. slow down and notice yourself in action, as though you were watching yourself on a movie screen. notice your face, your tone of voice; notice whatever thoughts and feelings show up in the moment. notice what is happening between you and your child-see if you can notice their face, how they are looking at you. what might their experience be? what patterns do you see? in doing so, you may evoke parents' mindful awareness of potentially unhelpful patterns-such as denial of self-care, autopilot, or avoidance. you may also help them notice and reinforce their "wins," of which they may be unaware. step 2: valued and committed action valued action in difficult times, when we are really struggling, the presence of potent long-term reinforcers can help us move forward in an adaptive way. values have the potential to fundamentally alter our relationship with adversity. adversity in the context of what is most important to us can help us be more willing and able to rise to the challenges we are faced with in meaningful ways. practitioners might spend some time with parents and suggest that they consider approaching their current context in a different way: see if you can step back for a moment and imagine that you could choose to make your time during this crisis about the things that are truly important and meaningful to you. if that were so, ask yourself, "who do i want to be during this crisis? what do i want this to be about? what would it look like if i acted toward my values?" practitioners may remind parents that every moment offers a choice and that in every moment parents can choose how best to use this time. this moment can be all about crisis parenting, or it could be about something more meaningful or valued. by connecting with values, we can transform struggle and uncertainty into an opportunity to connect with what matters to us most. committed action when we are on autopilot, stuck in patterns of behavior that are so ingrained we barely notice them, the ability to choose our next steps disappears. thus, you may engage parents in the simple practice of "pause, notice, choose." practitioners might ask, can you notice when you are connected to and acting accordingly with what you care about most, and notice when you are not, and gently bring yourself back to your intention whenever you notice you are off track? in addition, practitioners may encourage parents to make a promise to themselves about something that really matters and start small: "do the hard stuff in whatever order you like" and keep going. "practice everywhere, everywhen, everyhow, everymood, with everyone. don't stop" (sedley & coyne, 2020: p. 71 ). in doing so, practitioners may create a space for this crisis to be incredibly scary and difficult, but also meaningful and important. we may contribute to the creation of more helpful patterns of behavior that support engagement in values-based behavioral activation, or the regular practice of acting with intention in meaningful ways. step 3: self-compassion most of us struggle to offer ourselves the same kindness we offer to others, particularly in times of great stress. this situation is hard. this will be hard. self-compassion can be shaped and strengthened, even while we are struggling, and involves relating to ourselves with kindness and compassion, appreciating our common humanity and staying present and open to our pain and struggle (neff, 2012) . self-compassion builds resilience (e.g., beaumont, durkin, hollins martin, & carson, 2016; shapiro, astin, bishop, & cordova, 2005) and is a strong positive predictor of quality of life and overall psychological health (e.g., baer, lykins, & peters, 2012; van dam, sheppard, forsyth, & earleywine, 2011) . it is also an important "oxygen mask" for practitioners: "if a behavior analyst does not engage in self-compassion, they will likely have difficulties extending reciprocal compassion to others" (taylor et al., 2019, p. 660) . families may be faced with difficult decisions and situations where their values may conflict with what they are being asked to deal with. getting through this will require the willingness to stay with discomfort, rather than trying to fix it. self-kindness when everything around us feels chaotic and we are experiencing distress, our go-to response is likely to be one of "fight or flight." self-kindness has the potential to transform that fight-or-flight response into a caregiving or nurturance response, providing us with a sense of safety and resources. practitioners might begin to invite parents to treat themselves more kindly in session by asking, how are you doing? . . . perhaps take a moment and check in with your body, and ask it if it needs anything. is there something you could do right now to feel just 10% more comfortable? we might then invite parents to find just one moment, every day, to put down whatever they are doing and do something kind for themselves, even if that is simply allowing themselves to think about and focus on something other than all of this, just for a moment. self-kindness could even be shaped within session, perhaps starting with just pausing the session and encouraging parents to breathe into whatever they are experiencing, with kindness, before carrying on. self-kindness also creates a safe space for imperfection and mistakes, which will inevitably happen as we navigate through challenging situations. it creates a space where we can try, even when things might feel impossible, and reduces our tendency to be judgmental, self-critical, and harsh with ourselves and others. if parents are having a hard time offering kindness to themselves, practitioners might invite them to think about what they would offer a friend or their child at the end of a hard day and invite them to give that to themselves. if parents are struggling with making a mistake, guilt, or self-blame that won't let them go, practitioners could invite them to speak to themselves kindly: breathe into and soften around that self-critical part of yourself. create some space around it, and then tell it with kindness, "i know you criticize me because you are suffering. i see you suffering, and i am here, offering kindness and love for you." part of treating oneself kindly is prioritizing and creating space for small acts of self-care. invite parents when possible to share the work at home and encourage them to schedule breaks and do things to promote well-being. start building small patterns of well-being such as movement, social connection, or meditation practices. start small and make it doable. common humanity versus isolation in any moment, there are infinite reasons to be afraid and in pain, and there are infinite reasons to wonder and be grateful. we are all human. different people cope in different ways. self-compassion allows us to recognize that our experiences are common to humanity and we are not alone in our pain or suffering. practitioners can help parents recognize and remember this: we are all capable of amazing, heroic things, and we all make mistakes and struggle-we are all vulnerable and imperfect. mindfulness we cannot be compassionate toward our own and others' suffering while also ignoring, suppressing, and avoiding it. self-compassion involves staying open, present, and curious with respect to our own suffering and that of others. it is a nonjudgmental, gentle way of being with ourselves (our thoughts and emotions). practitioners can support parents in "learning to surf" the uncertainty and distress they are experiencing, rather than being swallowed up by it. they can invite parents to practice mindful attention to whatever they are feeling and carrying with them and to create space for whatever they are experiencing instead of struggling against it. in doing this, parents may be more able to stay fully present in what is happening, listening and responding where it is needed most, without being buried under or paralyzed by stressors. the covid-19 pandemic has resulted in a complete change in context. there are suddenly many things that we simply cannot do or cannot do in the same way that we previously did; it is easy to become overwhelmed. this situation reflects what evolutionary psychologists call "evolutionary mismatch," in which the environmental conditions change so swiftly, and so dramatically, that we find that our old patterns of behavior no longer work (li, van vugt, & colarelli, 2017) . this is a rude awakening, not just for families, but also for practitioners scrambling to adapt their family interventions. when working with families, we must stay sensitive to this huge context shift and be careful not to add yet another item to their already long list of things they "should" do or "have to be" doing, while also encouraging them with potentially meaningful suggestions. although structure and predictability may be helpful, suddenly implementing a high level of structure in a context that is not normally so structured (e.g., home) is likely to be experienced as adding to the stress of the situation and will be resisted and avoided by many. we must deliver self-care support in small, doable doses. even when the dose is so small that it does not appear to make a noticeable physical difference, it can still make an extraordinarily meaningful difference. there is no act of self-care that does not contribute to well-being. editor's note this manuscript is being published on a highly expedited basis, as part of a series of emergency publications designed to help practitioners of applied behavior analysis take immediate action to adjust to and mitigate the covid-19 crisis. this article was submitted on 4/10/20 and received final acceptance on 04/12/20. the journal would like to especially thank dr. amanda kelly for her expeditious review of the manuscript. the views and strategies suggested by the articles in this series do not represent the positions of the association for behavior analysis, international or springer nature. mindfulness and selfcompassion as predictors of psychological wellbeing in long-term meditators and matched nonmeditators measuring relationships between self-compassion, compassion fatigue, burnout and well-being in student counsellors and student cognitive behavioural psychotherapists: a quantitative survey development of the parental psychological flexibility questionnaire applied behavior analysis interventions that target improvements in mental health for parents of children with autism spectrum disorder: a narrative review evidence-based kernels: fundamental units of behavioral influence man's search for meaning: an introduction to logotherapy chronic inflammation in the etiology of disease across the life span self-compassion and dispositional mindfulness are associated with parenting styles and parenting stress: the mediating role of mindful parenting mindfulness for children and adults with autism spectrum disorder and their caregivers: a metaanalysis acceptance and commitment therapy: an experiential approach to behavior change acceptance and commitment therapy: the process and practice of mindful change a systematic review and metaanalysis of the effectiveness of interventions to improve psychological wellbeing in the parents of children with cerebral palsy psychological flexibility as a fundamental aspect of health the training experiences of behavior analysts: compassionate care and therapeutic relationships with caregivers. behavior analysis in practice the evolutionary mismatch hypothesis: implications for psychological science the impact of acceptance and commitment therapy on positive parenting strategies among parents who have experienced relationship violence the science of self-compassion self-compassion and well-being in parents of children with autism black americans face alarming rates of coronavirus infection in some states. the new york times coercive family process stuff that's loud: a teen's guide to unspiraling when ocd gets noisy mindfulness-based stress reduction for health care professionals: results from a randomized trial compassionate care in behavior analytic treatment: can outcomes be enhanced by attending to relationships with caregivers? behavior some cities see jumps in domestic violence during the pandemic self-compassion is a better predictor than mindfulness of symptom severity and quality of life in mixed anxiety and depression inflexible parents, inflexible kids: a 6-year longitudinal study of parenting style and the development of psychological flexibility in adolescents rethinking the theoretical foundation of sociobiology self care for health publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations ethical approval not applicable.informed consent not applicable. key: cord-310145-wvu79t45 authors: daly, bradford d.; gardner, rachel a. title: a case study exploration into the benefits of teaching self-care to school psychology graduate students date: 2020-10-23 journal: contemp sch psychol doi: 10.1007/s40688-020-00328-3 sha: doc_id: 310145 cord_uid: wvu79t45 it has long been established that school psychology practitioners experience high levels of burnout. as a means of preventing burnout among future practitioners, school psychology training programs are frequently encouraged to teach and model self-care to students. this is particularly important as the current generation of graduate students experience high levels of anxiety and depression, but there have been very few examples in the research literature of how training programs should teach self-care and whether it is actually effective. the current study presents results from an exploratory case study, which integrated self-care instruction into graduate school psychology curriculum with a small sample (n = 22) of first-year school psychology students across two separate cohorts. students created written plans with self-care strategies that they attempted to implement over the course of their first semester in graduate school. a qualitative review of their plans and written reflections revealed that students described many sources of stress upon entry into training, and most needed to revise their strategies for coping as stresses changed during the semester. overall, student reflections revealed that the self-care activities were helpful to meet the demands of their graduate education. with the field of school psychology facing shortages in the near-and long-term future, the profession can ill afford to lose practitioners or prospective practitioners due to attrition. an estimated 5% of school psychologists leaves the field each year for reasons other than retirement (castillo et al. 2014 ), a number that in most regions of the usa exceed the projected number of new school psychology graduates entering the field each year. while the exact number and reasons that school psychologists leave the field are unclear, one potential reason that has been proposed is the high level of susceptibility of practitioners to burnout. research of school psychology practitioners (e.g., wilczenski 1997; kaplan and wishner 1999; mills and huebner 1998; huebner and mills 1994; worrell et al. 2006 ) has consistently found that while school psychologists have high levels of job satisfaction, they nevertheless also experience high levels of emotional exhaustion, feelings of depersonalization, and reduced sense of personal achievement, which unmitigated may result in burnout. newman (2020) proposed that unaddressed burnout can lead to problems with professional competence and engagement in ethically questionable practices. application of self-care strategies has frequently been recommended as a means of preventing burnout and increasing meaning derived from work. in fact, engaging in self-care has been described as an ethical imperative by multiple authors (lopez 2016 ; barnett and cooper 2009) . newman (2020) defined self-care behaviors as ones that are used to "establish and promote physical and emotional wellness, and to allay stress" (p. 179); self-care behaviors serve to both mitigate stress and promote personal wellness, thereby ensuring the optimal quality of services provided by practitioners. selfcare has been conceptualized as a multi-dimensional construct, with some authors proposing four domains (newman) and others proposing six domains (butler et al. 2019) . common elements of self-care definitions include behaviors designed to promote physical wellness (e.g., physical exercise and nutrition), enhance cognition (e.g., professional development, supervision), promote emotional well-being (e.g., seeking counseling, communication), and deriving meaning from work (e.g., mindfulness practices, religious and spiritual practices). there is some correlational research regarding the effectiveness of self-care strategies on the functioning of mental health professionals. in a study of clinical psychologists, stevanovic and rupert (2004) found that psychologists who engaged in a greater number of self-care behaviors experienced greater job satisfaction. a survey of school psychologists (bolnik and brock 2005) found that 94% believed that engaging in self-care practices was important, and more frequent strategy use was associated with fewer physical symptoms of stress. coster and schwebel (1997) used a mixed methods approach to identify that 26% of psychologists had experienced personal impairment, and that effective strategies to address impairment included attending to personal relationships, going on vacations, striking a work-life balance, and developing self-awareness. in summary, this research evidence seems to provide at least some support for the importance of school psychologists engaging in self-care behaviors. based on these findings, researchers writing about self-care for psychologists frequently recommend that graduate programs directly teach self-care to prepare students to use self-care strategies in their future professional careers (newman 2020; huebner et al. 2002; barnett et al. 2007 ; barnett and cooper 2009 ), but there is very little empirical research to guide these recommendations. there are a small number of studies that have examined self-care strategy use by graduate students in mental health professions. myers et al. (2012) examined stress and self-care behaviors among clinical psychology graduate students and found that sleep hygiene, social support, and mindful awareness were related to lower stress levels. turner et al. (2005) , in a survey of school psychology interns, identified a number of strategies used by interns to manage stress including self-awareness activities, social activities, exerting control over professional activities, and appreciating intrinsic professional rewards, all of which were identified by the interns as being effective strategies. these studies provide some correlational evidence for the importance of self-care for graduate training, but the question of whether self-care behaviors can be successfully modified by training programs remains largely unexplored. several authors (lopez 2017; barton et al. 2019 ) have described various ways that school psychology training programs could integrate self-care into their curriculum, but there remains little evidence as to the effectiveness of these recommendations. lewis and king (2019) described efforts to integrate a self-care unit into social work students' field experiences, and provided qualitative evidence attesting to the benefits to students, providing a potential model for school psychology training programs to use. it is particularly important to consider the self-care needs of graduate students in school psychology given the overall context of high mental health needs among graduate students in general. a recent study (evans et al. 2018) found that graduate students both in the usa and internationally have six times the rate of depression and anxiety in comparison to the general population. there is some reason to believe that these rates may be higher in school psychology programs due to lower rates of financial support than other disciplines (proctor and truscott 2012) and the nature of school psychology training that involves intensive coursework and fieldwork (barton et al. 2019) . a study of training programs in school psychology (gadke et al. 2018) found that in the 2016-2017 academic year, one student withdrew from their training program for every 9.1 graduates at the specialist level and for every 9.6 graduates at the doctoral level. based on this information, it seems reasonable to consider school psychology graduate students a population that is vulnerable to stress and anxiety, yet vital to the future health of the school psychology profession. training programs need to develop a deep understanding of the sources of stress for graduate students in school psychology and a means by which to assist students in coping with these stressors. with self-care strategies having emerged as a promising practice in mitigating stress and burnout, training programs should seek to design ways to integrate self-care into their curriculum and monitor the effectiveness of doing so. an important question to consider when attempting to train students to apply self-care strategies is an understanding of the nature of self-care. much of the correlational research into self-care practices by mental health professionals has at times defined self-care as engagement in a number of coping behaviors at a specific point of time (e.g., stevanovic and rupert 2004; bolnik and brock 2005) . this research tradition suggests that self-care might be best conceptualized by considering the volume and diversity of coping skills employed by individuals. on the other hand, the im-paact framework (brown 2019 ) defines self-care as a more fluid concept, comprised of four stages: (a) prioritizing self-care, setting goals, incorporating into schedule, (b) implementing self-care plan and refine as necessary, (c) connecting internally and with an external social support network, and (d) thrive by fully engaging in the self-care plan and regularly re-assessing and adjusting the plan as necessary. these same core elements are consistent with the self-care plans developed, implemented, and revised by graduate students in the current study. moreover, drawing from the related literature on coping strategies for managing stress, coping skills have been theorized to fall within two distinct categories (i.e., problem-focused or emotion-focused; mcnamara 2000). using active problemsolving is an example of problem-focused coping. in general, such problem-focused coping is associated with better functioning and management of stress compared to emotionfocused coping. arguably, proactively planning for self-care in the midst of school-and work-related stress can be considered a form of problem-focused coping. the theoretical orientation is important because trainers interested in incorporating self-care into school psychology curriculum may make different decisions about how and what to cover based on an understanding of the construct of self-care. the present study was designed with two primary goals in mind. first, it is important for school psychology trainers to better understand the nature of the construct of self-care and how it can meet the needs of graduate student trainees. second, it is important to understand whether an intervention aimed at self-care could be effective as a means of addressing stress experienced by trainees in graduate school. therefore, this study was designed to provide an in depth understanding of the self-care practices of two cohorts of graduate students following a sustained semester-long intervention to integrate self-care into the school psychology training curriculum through a systematic case study inquiry. case study research has a long history in many disciplines, and is especially appropriate in circumstances in which an in-depth description of a case may inform future theory, research, and practice (creswell and poth 2018) . case study research is particularly useful in situations in which the primary research questions involve understanding the how and why behind a construct and intervention, especially when conducted over a period of time (yin 2018) . in this study, an analytic approach called explanation building (yin) was undertaken to provide a detailed examination of the experiences of the graduate students while experiencing a self-care intervention, intended to help other researchers and trainers conceptualize the fluid nature of self-care and whether an intervention based on the im-paact model could improve self-care practices among graduate students. two separate cohorts of graduate students across 2 years (n = 22) enrolled in their first semester at a school psychology training program participated in the present study. within each cohort, 100% of enrolled students participated in the self-care intervention in the present study and all completed the study through the three measurements. the school psychology program is a combined specialist level and doctoral level (psy.d.) program and is located in a small private university in the northeastern usa. in the present study, 14 of the participants were members of the specialist program and the remaining 8 were enrolled in the doctoral program. all students participated in the intervention described in the present study as part of the required coursework for their field experience seminar. per the university's committee on ethical research with human subjects, all participants were given the option to exclude the use of their anonymized data for this project. due to the small sample size in the present study, detailed demographics on the participants could not be reported due to the risk of revealing their individual identities; however, statistics on the overall graduate program during the time the study was implemented are available to convey information about the characteristics from the population that the participants derived. as reported by gadke et al. (2018) , approximately 14 to 16% of school psychology graduate students nationwide are male, and approximately 27% are students of minority status. at the time of the study, the program overall had a percentage of students of minority status of 8%, which is lower than the national average cited above. the percentage of male students enrolled in the program overall was 16%, which is in line with the national average cited above. because of the very small number of male and ethnic minority students who were participants in this study, in all responses, identifying information was masked to prevent revealing identities. in some cases, participant responses were altered slightly to remove or change information that could be identifiable, in order to mask their identities. the two cohorts participating in the study were enrolled in consecutive academic years. the first cohort (n = 13) was larger than the second cohort (n = 9), but the group composition was overall similar. the large majority of students were in their early twenties and were enrolled in graduate school within a year of receiving their undergraduate degree; however, it is not possible to provide detailed age data due to risks to breaking participant confidentiality. per yin's (2018) recommendations, case study research can provide support for the external validity of their claims through replication of its procedures; therefore, having two separate cohorts complete the self-care intervention, while the overall number of participants is small, helps to strengthen the validity of the conclusions. the school psychology training program at which participants were located is housed within a college of graduate studies in counseling, psychology, and education. the school psychology's specialist program is approved by the national association of school psychologists and the psy.d. program is accredited by the american psychological association. at the time of data collection, there were 4 full-time faculty with primary appointments to the school psychology program. the training program uses a cohort model with both specialist and doctoral students taking the same coursework in the first semester. students are required to take a total of 18 credit hours in their first semester. the first semester within the training program emphasizes acquisition and maintenance of personal and professional skills. therefore, students take foundational coursework in learning and cognition, psychometrics, individual norm-referenced assessment, interpersonal communication skills, cultural awareness, and perspectives in school psychology. in addition to coursework, students in the training program are required to enroll in a school-based practicum experience 1 day per week for a total of 90 h in the first semester. finally, students also are assigned a graduate assistantship, which provides partial tuition remission in exchange for 5 h of work per week. one unique characteristic of the training program is its location, which is in a rural community over an hour's drive away from major population centers. this provides students with experiences in rural schools and populations, but does make it more difficult for students who are working full time to commute. therefore, many of the students live in apartments in fairly close proximity to the university during the academic year. the primary author served as the instructor for the field experience course and the facilitator for the self-care intervention. in this role, there was the advantage of being embedded within the system and milieu along with participants, as well as the drawback of potential lessened objectivity from serving in an evaluative role to the participants. the instructor was a white male in his late thirties, and was in his first 2 years as a fulltime core faculty within the school psychology training program over the course of the intervention. prior to joining the program faculty, the instructor had 12 years of experience as a practicing school psychologist, and drew heavily on these experiences in describing the importance of self-care throughout the intervention. both cohorts participated in the self-care intervention in their first semester field experience seminar. the overall goal of the intervention was to help participants reach the thriving state of self-care based on the im-paact model (brown 2019 ) for application of self-care. the transactional model of coping emphasizes active application of coping in response to appraisals of stressful events (lazarus and folkman 1984) , and intervention in coping skills emphasizes application of problem-focused strategies and reducing use of avoidancefocused strategies (mcnamara 2000). the thriving state of self-care suggested by im-paact model predicts that this coping approach can be developed through promoting the prioritization of self-care, developing and evaluating a plan, and connecting internally to self-care and externally to others (brown 2019) . a summary of the steps of the self-care intervention designed to adapt the im-paact (brown 2019) framework is included in table 1 for quick reference. during the first week's seminar, participants were prepared for their practicum experience through discussions about expectations and requirements. the first step of the self-care intervention, a didactic discussion led by the instructor, was embedded into this initial seminar. this discussion began with a short lecture about the effects of stress on professionals in school psychology, and the progression of unhealthy stress that can lead to burnout and problems of professional competence, based on the models of stress proposed by newman (2020) and mcnamara (2000) . participants were prompted to propose and share potential sources of stresses in their lives that could potentially lead to this unhealthy progression. the instructor then described that problematic stress could therefore lead to professionals engaging in ineffective and unethical practices. finally, the instructor introduced the notion that self-care strategies are posited to be a potential buffer against this negative progression. next, participants engaged in self-study with the goal of creating a plan with strategies that they could apply for selfcare. creation of a written plan to address stress through selfcare that is revised over a period of time is consistent with theoretical models of self-care (brown 2019) and parallels coping skill training as proposed by mcnamara (2000) . a series of readings and websites were provided to participants (see table 1 for a list) to help them to generate ideas about how to structure and design a self-care plan. the participants were not given specific criteria for what format or content to include in their plans, but were advised to create plans that were multidimensional, individualized, specific, and realistic, so that the plan would reduce stress without adding new stress (newman 2020; lewis and king 2019) . participants submitted their self-care plans and a reflective writing piece to the instructor prior to the second week of class. these responses were used to facilitate a group discussion in the following seminar session. participants had the opportunity to share stressors and strategies they attempted to incorporate into the plans, which also helped to serve as member checks to ensure the credibility of the instructor's interpretations of their written responses. during this discussion period, the instructor primarily engaged in reflective listening while encouraging participants to think about ways that they could ensure the effective implementation of their plans. participants' self-care plans and written reflections were assigned a pass/fail grade based on completion of the requirements, which all participants did successfully. a brief written response was provided by the instructor to each participant, commenting on content in the student's reflective writing and encouraging their use of self-care strategies. the following is an example of one of these feedback comments: i'm glad to see the honesty in your response about feeling stressed. it's important to recognize when your stress level goes up and down so that you can react accordingly. don't be afraid to reach out to others, it's not a sign of weakness! good luck with following your self care plan this semester and managing your stress. discussion about implementing self-care strategies was embedded throughout seminars over the next several weeks, which was integrated with discussions about their professional work behaviors, and the nature of school psychology service delivery. while participants were encouraged to adjust their self-care routines throughout the semester, they were formally asked to revise and reflect on their self-care plans at two points. seven weeks into the semester (time 2), participants were required to submit an updated self-care plan and written reflection in which participants were asked to reflect upon how well their plans worked, and to describe how they adjusted their plans to better meet their needs. the instructor used their responses in the following seminar session to again facilitate a group discussion about stress and self-care. finally, this process was repeated at the fourteenth week of the semester (time 3) as a means for participants to have a summative examination of their self-care and stresses in their first semester of graduate school. as before, their responses were used to lead a debriefing session in the last field experience seminar session for participants to reflect on the role of self-care in their graduate education and to plan for the future. qualitative data used for the study included the student's selfcare plans and written reflections submitted as part of the coursework requirements at three measurements: time 1, time 2, and time 3. reflections and plans were both de-identified with student names and identifying characteristics removed from responses prior to analysis. as sources of data for this project, the written reflections were useful in understanding participants' cognitive appraisals of stressors and their coping responses, making them amenable to interpretation based on the transactional model of coping (lazarus and folkman 1984) . yin (2018) described tactics that can be used in case study research to support construct validity of conclusions. the first such tactic is through the use of multiple sources of information. while participant interviews and seminar discussions were not transcribed for separate analysis, they did provide external verification of the contents of the participants' written reflections, helping to support that they represent an accurate account of their experiences. a second tactic described by yin is establishing a clear chain of evidence for case study data. to analyze the written documents in this study, de-identified student reflections were initially downloaded from the online course management software. these raw responses were compiled into a single document in microsoft word. after compilation, participant responses were read by the primary author twice to identify excerpts of the response that could be relevant to understanding the responses of the participants based on the stages proposed by the im-paact model (brown 2019) . these excerpts were then extracted into a separate research database in microsoft excel, thus providing a clear chain of evidence for the qualitative data to be analyzed. once the participant response database was compiled, the analysis strategy for these data sources was developed based on recommendations for case study research by yin (2018) and creswell and poth (2018) . in general, a pattern matching approach was used to analyze the participant responses based on the im-paact model (brown 2019) and transactional model of coping (lazarus and folkman 1984; mcnamara 2000) . yin described pattern matching as a technique in case study research involving searching for patterns in the data predicted by theory or prior research. a subset of this approach, explanation building, is particularly useful when step brief description in the first field experience seminar, students were introduced to the idea of self-care as a means to avoid burnout. 2. guided self-study students were assigned to research self-care through a collection of articles and websites. specific readings assigned included: â�¢ self-care: the missing link in best practice -part i (lopez 2016) â�¢ self-care: the missing link in best practice -part ii (lopez 2017) â�¢ developing a self-care plan (reachout.com, n.d.) â�¢ best practices in early career school psychology transitions (silva et al. 2014) â�¢ self-care starter kit (butler and mcclain-meeder 2015) 3. self-care plan design students were required to design their own self-care plan and submit it to the instructor prior to the second week of the semester. at time 1 (1 week into the semester), time 2 (7 weeks), and time 3 (14 weeks), students completed written reflection about their sources of stress and how their self-care plan was working or was not working to help to manage these stressors. attempting to understand how and why observed outcomes occur, based on a prior theoretical model. this approach was selected as the major goals included understanding how participants appraised and planned self-care strategies to cope, how participants adjusted these plans over the course of the semester, and how the participants evaluated the intervention and plan as being effective in helping them meet the stressors experienced during graduate school. based on yin's (2018) recommendations, the analysis of the qualitative data followed an iterative process. the authors started the process with a conceptual model for stress and self-care, specifically the transactional model of coping (lazarus and folkman 1984; mcnamara 2000) and the im-paact framework (brown 2019 ). the analysis started at a broad level through an initial reading of all responses in the response database, followed by a closer reading at the element level within responses to examine for information that matched patterns predicted by theory and might yield the explanatory information needed to respond to the research questions. these responses were then developed into codes through which themes in responses could be identified, and as yin recommended, these initial themes were then compared to the prediction based on the theoretical models. finally, the explanations were again compared to the data, and the second cohort provided an opportunity to test these interpretive explanations with a new data source. responses were found to match patterns that were extracted into three major themes upon which the findings section is organized. several efforts were undertaken to ensure the validity of these analysis procedures. first, and very important as identified by yin (2018) , the authors considered several alterative and rival interpretations at multiple stages of the analysis process. as one example of such an explanation, the authors were aware that participants could experience stressful life events outside of graduate school which could influence their implementation and selection of self-care activities; to help guard against this threat, all responses were examined for information about outside stressors that could potentially have affected the individual participants. other rival explanations considered during the analysis phase are noted in the findings section. another strategy used to support the validity of the analysis was through triangulation of multiple information sources (creswell and poth 2018) . member checking to ensure credibility of the conclusions happened throughout the course of the semester through in-class discussions of the themes the instructor identified in participants' responses. the instructor also debriefed with the participants as a group following the submission of final grades to help make sure their responses would be similar in theme to the written products used for analysis in the present study. prolonged engagement with participants over the course of the academic semester helped the author to have a relationship that encouraged honest and candid responses, and is considered to be another good practice in qualitative research (creswell & poth) . the reliability and credibility of the explanations were supported in the research process through a memoing notetaking procedure to document contemporaneous process notes (creswell and poth 2018) . a replication of the intervention and data analysis of the study with two separate cohorts gave an opportunity for initial explanations developed after the first year to be checked with new data in the second year of the study, and provided additional support for the findings (yin 2018) . finally, while it must be noted that the primary author was the course instructor and therefore may have been prone to bias, being embedded with the participants over the course of a semester also helped to lend credibility to the analysis (creswell & poth) . the im-paact model (brown 2019) described the first stage of thriving with self-care to be prioritization of self-care. to support the prioritization of self-care, and participant development of problem-focused coping strategies (mcnamara 2000), the selfcare intervention began providing participants with didactics about self-care and stress, and requiring them to make an appraisal of their current stressors. a summary of stressors identified by participants at time 1 is presented in table 2 . as noted in the table, the majority of participants reported stress in relation to the rigors and difficulty of their graduate coursework, and their ability to stay organized and manage time to effectively meet these challenges. many of the participants described the origin of this stress being internal, as exemplified by the following response from a male graduate student in his early twenties: the biggest stressors in my life are largely internal. they're preconceived notions about what i should be doing, or what i should be able to do "on my own." they're also issues surrounding a consistent drive to "accomplish" as much as possible, to the detriment of my own health and well-being. by requiring participants to engage in this self-appraisal, the goal of the intervention was to help them prioritize self-care and develop plans to help them meet their needs, thus adopting a problem-focused coping strategy (mcnamara 2000) . per the im-paact model, "the goal at the prioritize stage is to identify a variety of activities that seem most likely to bring fulfillment and are realistic for the particular individual. consideration for personal interests and resources is key" (brown 2019, p. 41) . that said, the research literature in self-care gives little guidance as to how professionals should organize, plan, and implement self-care strategies. through an analysis of participants' self-care plans developed for time 1, it appears that the strategies that participants included in their initial plans largely mirrored the stressors they reported at the start of graduate school in primarily addressing academic and social-related sources of stress. all participants organized their strategies into several domains, which was recommended in some of the readings they completed as part of the assignment (e.g., butler and mcclain-meeder 2015) . a summary of the most common domains included by participants, and examples of strategies that they included under those domains, can be found in table 3 . as noted, it appears that participants developed plans that were tailored to their individual needs based on their selfappraisal of stressors. all participants included strategies that were intended to support their ability to keep up with coursework and manage their time. all participants included a domain for physical health that initially included some kind of strategy related to physical activity or exercise, ranging from planning on visiting the gym 5 days a week for exercise to going for a walk regularly. a large majority of participants (n = 17; 77.3%) included spending time with a significant other (defined in the study as spouse, partner, girlfriend, boyfriend, fiancã©) as part of their self-care plan. consistent with previous research with self-care (lewis and king 2019), the majority of participants (n = 20, 90.1%) included a spiritual health domain, which included a large number (n = 9; 40.9%) who indicated that religious expression, including prayer or attending religious observances, was an important part of their self-care. as noted, it was important to the study's analytic procedures to search for information that did not fit predicted patterns. to mitigate the effects of a history threat on interpretations, the authors considered it important to note when participants described unusual discrete events that could impact their stress and coping response. three participants did report outside events which were coded to be in this category, for example, the death of a loved one and a serious health issue. responses for these participants were flagged and efforts were made to analyze their descriptions of stressors and coping separately, so as to avoid drawing conclusions about the idiosyncratic responses to these events. it is important, however, for trainers to note the potential impact of similar events on the stress and coping of graduate trainees. finally, one theme present in the responses of social work trainees in previous self-care research (lewis and king 2019) was that of compassion fatigue and secondary trauma due to stressful situations at their field placement. while these themes were expected in the present study, they did not feature in participant responses outside of two participants. the authors interpreted this finding as being related to the typical activities at the field placements in the first semester of the training program, which primarily involve shadowing, observing, and assessment, as opposed to providing mental health counseling. the intervention procedures included several features which were designed to support participants' implementation of selfcare strategies, assess their plan, connect with self-care both internally and externally, and adjust their plans accordingly. these included the cycles of reflections and revisions at time 2 and time 3 and the group discussions about self-care in the seminar. the im-paact model (brown 2019) predicts that these processes are important to successful application of selfcare in response to constantly shifting sources of stress. participants were asked at time 2 and time 3 to re-evaluate their sources of stress to provide an insight into their shifting appraisals of stress. the most prominent theme in participant responses regarding the evolution of their stresses was the need to find a balance between academic demands and other activities. there was a wide variance of responses to how participants evaluated their success at finding this balance at time 2 and time 3, with participants describing the semester overall as causing very little stress and some conveying that they experienced extreme stressors. consistent with other work on self-care that has followed individuals over a length of time (e.g., lewis and king 2019), self-care practices for participants in this study evolved over the course of the semester in response to their shifting appraisals of stress, with participants experiencing some successes and challenges implementing strategies that they initially thought would be successful. all participants made adjustments to their plans at time 2, and all but two made further adjustments at time 3. a summary of the most common adjustments to plans can be found in table 4 . as noted, most participants experienced difficulties in time management as a primary barrier for regular application of self-care strategies. many participants reported that they initially under-estimated the time that coursework, practica, and other responsibilities related to graduate school would take. one student, who had written at the start of the semester that graduate school had already threatened to become overwhelming, commented at the end of the semester, "i quickly realized that those stressors from undergrad and the ways i would cope with them, were not going to help this year." as noted in table 4 , there were some participants for whom the cycle of revision and reflection on self-care plans provided impetus to seek out counseling support. all of these participants described the change as being very positive; for example, one female graduate student in her early twenties wrote on the benefits of seeking counseling: "i am so glad i started following this assignment because i have never felt so mentally healthy and fit in my entire life. i feel like a whole new person this semester because i am prioritizing my mental and physical health." one domain of self-care that participants found particularly difficult to implement was in the area of spiritual health. onethird of participants who originally included strategies regarding religious expression removed these strategies when revising their plan. this finding was an interesting difference from results reported in other research (lewis and king 2019), but overall is consistent with the im-paact model in terms of participants developing a plan that is adapted to their needs. theme 3: participants perceived that the intervention procedures supported their thriving with self-care brown (2019) proposed that the final stage in the implementation of self-care based on the im-paact model is characterized by thriving. reaching this stage does not mean that a professional's self-care plan is a finished product, but rather that the professional has fully engaged in a plan for self-care which is continually re-assessed and adjusted to meet changing needs. individuals at the thriving stage will have prioritized their wellbeing as a fundamental aspect of their professional effectiveness. in the present study, evidence that participants were in the thriving stage was evaluated through how they described their reactions to their self-care plan and their descriptions of their approach to self-care as part of their professional functioning following the semester-long intervention. importantly, a participant who is thriving could still struggle with implementing certain aspects of her plan, as long as self-care was clearly described as a priority and she provided evidence of committing to a continual cycle of assessment and adjustment of a self-care plan. based on the model, all participants in the study were characterized as being at least partially in the thriving stage of self-care at the end of the intervention. due to the richness of their responses, excerpts from three student reflections are presented below, which represented the continuum of responses to these questions (yin 2018) . the first such response, from a female participant, demonstrated the importance, predicted by the im-paact model (brown 2019) , of prioritizing self-care, and adjusting self-care behaviors to provide a balance of thriving in a way that enhanced productivity. the participant also described a commitment to continuing these practices in her graduate school and professional career, an important mark of thriving: overall, i think that having a self-care plan has been helpful this semester. if i had not thought about doing activities that i enjoy or that help me to relax, i think my only focus would have been school work. i am glad that through this assignment i was able to be reminded about the importance of taking time for myself and doing activities that i enjoy. i also think that while implementing my self-care plan took time away from completing school work, having that break made me more productive once i started school work again. i think that continuing to implement my self-care plan will be helpful as i continue through graduate school and begin working as a school psychologist. the second illustrative excerpt, from a male participant, exemplified how participants described the role of self-care as fundamental to their future professional functioning: i imagine that any professional career i choose will come with assorted ethical dilemmas and stressinducing deadlines. such troubles must not only be met with adequate clinical expertise, but an effective self-care regimen. i imagine that as i become more familiar with the program, and how best to formulate a self-care plan, i will be extremely prepared for these situationsâ�¦ my experiences will self-care throughout this semester, and the forthcoming, will be influential while rival explanations were actively considered in making interpretations of thriving in participant responses, such as whether some outside influence rather than the intervention procedures might have led participants to make these statements, it is important to point out that the design of the research made it impossible to rule out some alternate explanations for the results. one example is that of a maturation threat; in other words, that the experiences of the participants could simply be explained by normal changes that would have occurred over the first semester in graduate school even in absence of any intervention related to self-care. while some participants described outside stressful events or mitigating factors in implementation of their plans, all nevertheless attributed their commitment to self-care at least in part to the semester-long intervention. despite the focus in the field of school psychology in attracting and retaining professionals to meet the personnel shortage, and the long-recognized risks of burnout in the profession (e.g., huebner & mills, 1994) , there is little research on the application of self-care strategies as a means to prevent burnout and attrition. this is especially important for training programs, who obviously play a large role in developing new school psychology professionals to address personnel shortages. while there are many scholars (e.g., newman 2020; huebner et al. 2002; barnett et al. 2007 ; barnett and cooper 2009 ) who have recommended that training programs include self-care in their curriculum, most of the existing research into self-care is correlational, and therefore, it is unknown how training programs should best accomplish this among many other priorities, and whether interventions to teach self-care are effective. the present study attempted to address this shortage in the literature by developing an intervention for self-care that was implemented over the course of the semester and documenting outcomes of the intervention. as a case study example of a self-care intervention, this study is intended to guide the development of future research, as a proof of concept that a selfcare intervention developed based on the im-paact model and the transactional model of coping (lazarus and folkman 1984; mcnamara 2000) can be feasibly integrated into school psychology training. all participants who participated in this self-care intervention considered the creation of a self-care plan in the context of their field experience class, with check-ins to monitor and adjust the plan, to be a helpful exercise. several participants were quite enthusiastic, reporting that the stressors they experienced in graduate school were much more intense than anticipated. consistent with research documenting high levels of stress and anxiety among graduate students (evans et al. 2018) , participants in the present study described many and varied stressors at the start of their graduate education. the largest source of stress was graduate training itself, with students worrying about being able to manage the volume and difficulty of the material. students also frequently expressed anxiety regarding managing their personal and family relationships amid the demands on their time caused by coursework. students participating in this study designed self-care plans that appeared to be geared to meet the stresses they anticipated; however, many of the students found their initial plans to be inadequate to meet the demands of the training program. the im-paact model (brown 2019) described application of selfcare to be a process that best results in a plan that is individualized, continually assessed, and adjusted to changing stressors. previous research with self-care for students in mental health training programs (lewis and king 2019) also documented that self-care strategies for students evolved over the course of the semester and needed to be monitored and revised to be effective. there was evidence that the intervention procedures helped to support these behaviors among participants; future research should further explore the process of adopting and sustaining self-care behaviors, to inform efforts at instructing students and practitioners to engage in these behaviors. while the present study described a case study which should suggest several important hypotheses for future research to consider, there are some important limitations in the design of the study that must be taken into account in interpreting the results. first, the study's goal was to obtain an in-depth understanding of the stresses that school psychology trainees face and the strategies they use to cope with those stressors after a self-care intervention. as a result, the participants were all enrolled in a single graduate program, and were overall a more homogenous group in comparison to school psychology graduate students overall. this may be particularly important if considering applying the conclusions of this study to students who are members of a minority group. proctor and truscott (2012) for example found that themes of fitting in with other cohort members as being a paramount concern to students of minority status, but in the present study among largely white european american students this theme was much less prominent. future research should therefore consider using a larger and more heterogeneous sample to understand how the study's conclusions might extrapolate to students of minority status. the second important limitation was the lack of a comparison group to determine whether any described findings are causally related to the self-care intervention. without a control group, the design of this case study was such that it could not rule out whether, for example, the experiences described by students might simply represent normal maturation in response to starting a graduate program. finally, an important limitation for the present study was in nature of the measures used for data collection and analysis. while efforts were taken to ensure the dependability and credibility of the data and conclusions, students were submitting the artifacts for a grade in their course, and may have been incentivized to exaggerate the importance or value of the self-care plan. likewise, there were no external measures to estimate how often students were actually implementing strategies as they described in their reflections, nor any quantitative measures of stress and burnout. despite these limitations, the present study should provide researchers with a proof of concept model for embedding selfcare into school psychology training. given the research into graduate student mental health (e.g., evans, 2018) and especially when considering the covid-19 pandemic, for which there have already been documented negative effects on mental health in general (gao et al. 2020) , it is important to consider the mental health needs of students enrolled in school psychology training programs. furthermore, it is an important professional outcome of training for students to develop coping mechanisms while in training. it is vital for future research to extend the understanding of the construct of self-care and explore interventions that can help inform practice and training recommendations. creating a culture of self-care in pursuit of wellness: the self-care imperative incorporating selfcare into your graduate school career the self-reported effects of crisis intervention work on school psychologists hazards of our helping profession: a practical self-care model for community practice self-care starter kit six domains of self-care: attending to the whole person personnel needs in school psychology: a 10-year follow-up study on predicted personnel shortages well-functioning in professional psychologists qualitative inquiry and research design: choosing among five approaches (4th) evidence for a mental health crisis in graduate education nasp report of graduate education in school psychology mental health problems and social media exposure during covid-19 outbreak burnout in school psychology: the contribution of personality characteristics and role expectation best practices in managing stress and burnout school psychology trainers' identification of current stressors in the work lives of urban practitioners. a comparison study stress, appraisal, and coping teaching self-care: the utilization of self-care in social work practicum to prevent compassion fatigue, burnout, and vicarious trauma self-care: the missing link in best practice -part i self-care: the missing link in best practice -part ii stress in young people: what's new and what can we do a prospective study of personality characteristics, occupational stressors, and burnout among school psychology practitioners self-care practices and perceived stress levels among psychology graduate students the school psychology internship: a guide for interns and supervisors reasons for african american student attrition from school psychology programs developing a self-care plan best practices in early career school psychology transitions career-sustaining behaviors, satisfactions, and stresses of professional psychologists intern self-care: an exploratory study into strategy use and effectiveness marking the school psychology lifespan: entry into and exit from the profession school psychologists' job satisfaction: a 22-year perspective in the usa case study research and applications acknowledgments the authors would like to thank jennifer daly and nicholas sanders for assistance with copyediting and manuscript preparation.data availability the datasets generated during and analyzed during the current study are available from the corresponding author on reasonable request. conflict of interest the authors declare that they have no conflict of interest.ethics approval the research reported in this manuscript was classified as exempt by the institutional review board at a small, northeastern private university. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.dr. bradford daly is an assistant professor and program director in the school psychology program at alfred university. he has 12 years of experience as a practicing school psychologist and continues to consult in public schools. he is interested in applications of positive psychology and professional issues of school psychologists, particularly at the secondary school level. recently he has contributed to a project involving the effects of social media on the wellbeing teenagers.dr. rachel gardner is an assistant professor of school psychology at alfred university. her primary professional interests include tiered school-based mental health services and promoting student' subjective well-being. her research interests include the impact of social media usage on adolescents' wellbeing, provision of evidence-based mental health services within an mtss framework, and positive psychology interventions applied to youth in school settings. key: cord-350569-dtxtjtfo authors: kasoka, kasoka title: autonomy in hiv testing: a call for a rethink of personal autonomy in the hiv response in sub-saharan africa date: 2020-06-13 journal: med health care philos doi: 10.1007/s11019-020-09959-y sha: doc_id: 350569 cord_uid: dtxtjtfo the author reviews various conceptions of autonomy to show that humans are actually not autonomous, strictly speaking. he argues for a need to rethink the personal autonomy approaches to hiv testing in sub-saharan africa (ssa) countries. hiv/aids has remained a leading cause of disease burden in ssa. it is important to bring this disease burden under control, especially given the availability of current effective antiretroviral regimens in lowand middle-income countries. in most ssa countries the ethic or value of personal autonomy or self-determination is promoted as primary in hiv testing decision-making. ssa policymakers have an ontological and moral duty to adopt hiv testing policies that reflect human and medical realities, relationships, local contexts, and respect human rights for both individuals and others who are affected by hiv in society. without rethinking the value of autonomy in hiv testing decision-making, the article cautions that attainment of the sustainable development goal (sdg) 3 and the unaids fast-track strategy that explicitly call to end the epidemic by 2030 will not be feasible for ssa. the case of covid-19 pandemic has more than ever presented to the world that individual autonomy in society is at best conditional and relational. the coronavirus intrusive measures taken to contain the virus expose the fundamental problem in metaphysics-the issue of what makes a person the same over a period of time-and the moral dilemma posed in bioethics by the fact that an individual who lives in society with others is promoted as a sovereign of her own body, medical choices and life. this dilemma might otherwise be expressed: 'what makes a person the selfsame person today as who he or she was yesterday' (ndete 2016) , and what does autonomy mean to an individual whose exercise of self-governance has inescapable ramifications on the wellbeing and rights of others. thus, should there be a need to rethink the personal autonomy 1 premising of informed consent requirements in hiv testing in most sub-saharan african (ssa) countries, since informed consent requirements in hiv testing are mainly premised on personal autonomy? childress 1979/2000; fraser 2005; united nations 2009; naidoo and vernillo 2012) . or there isn't a need to rethink because humans are, as kantian and related notions of autonomy tell us, normatively and narratively sovereign selves? in this article i seek to show that personal autonomy, strictly speaking, is an illusion, and its primacy in healthcare ethics is morally problematic. in most of ssa countries the hiv prevalence has stabilised at high rates. the ssa region carries a disproportionate hiv burden, accounting for 70% of the worldwide burden of infection (bulstra et al. 2020) . hiv/aids is a leading cause of morbidity and mortality in the region (dwyer-lindgren, et al. 2019 ). 2 this is despite that major scientific breakthroughs (availability of effective hiv therapy) that have shifted the hiv paradigm that was once was considered a death sentence are now mostly available in the region. even with the availability of hiv medication in ssa countries like zambia, aids still remains the most common cause of death. 3 and yet, individual citizens are still celebrated and told through hiv laws or policies that they have a right to refuse hiv testing because they are sovereigns of their own health, life and destiny (castell v. de greef 1994; southern africa litigation centre 2012) . therefore, does this temptation and pursuit to view ourselves as autonomous hiv testing decision-makers blind us to an observable reality that shows that as humans we are interdependent and inextricably social and socialised beings? three decades into the hiv epidemic, hiv still poses a real health challenge from which no country in the world is immune, particularly ssa countries. according to unaids' factsheet, at the end of 2019 37.9 million people worldwide were living with hiv (unaids 2020a, b, c) . the same source indicates that 74.9 million people as of the end of 2018 became infected with hiv since the beginning of the epidemic. of the 74.9 million infected, 32 million have since died from aids-related illnesses. this makes hiv/ aids one of the major causes of morbidity and mortality in the world. hiv/aids is the second leading cause of death in ssa (business insider 2017). given the threat of the epidemic, it is not surprising that all the united nations member states agreed to reach certain targets in response to the disease (suthar et al. 2013 ). these targets were set to be achieved by 2015. some of the targets included the reduction of sexual and parental transmission of hiv by 50%, elimination of vertical hiv transmission, reduction of tb deaths among people living with hiv by 50%, and delivery of art to 15 million people (suthar et al. 2013; udjo and lalthapersad-pillay 2015) . it was noted that the achievement of such goals requires that people test for hiv since it is only through knowledge of one's serostatus that one can be linked to prevention, treatment and care services (suthar et al. 2013) . it is encouraging to note that such efforts have led to significant degrees of progress in response to hiv. overall, hiv infections are approximated to have been reduced by 40% between 2000 and 2013, with 13.6 million people globally reported to have been receiving art as of june 2014 (united nations 2015) . at present, new worldwide efforts are being made to end the epidemic by 2030. on 8 june 2016 united nations general assembly (unga) member states adopted, also in the light of the 2030 agenda for sustainable development and other, a new political declaration that seeks to end aids by 2030 (un general assembly 2016; un news centre 2016). the declaration includes a set of time-bound targets to fast-track response to reach three identified milestones by this year (2020). the 2020 milestones being: reduction of new hiv infections globally to less than 500,000; ensure that 90% of people infected with hiv know their hiv status, 90% of people who know their status are on put on art, and 90% of those on art have suppressed viral load (unaids 2015 (unaids , 2016 un news centre 2016) . 4 according to unaids, scale-up of art has put the reach of the global commitment to end hiv by 2030 on track (unaids 2016) . moreover, kharsany and karim state that the substantial declines in hiv infections are the result of hiv testing scale-up and widespread coverage of art (kharsany and karim 2016, p. 35) . thus, it is apparent that the above unga targets can only be achieved if there is an increased uptake of hiv testing and counselling (htc), and increased access to hiv prevention and care services (suthar et al. 2013, p. 23) . recognising the critical importance of hiv testing, indeed one of unaids' 90-90-90 2020 targets is that 90% of of all persons living hiv will know their hiv status (unaids 2020a, b, c) . as of 2018, 79% of all plhiv knew their hiv status (unaids 2020a, b, c) . the importance of hiv testing uptake cannot be overemphasised. its advantages include: being able to initiate early treatment for those who test positive at the time their immune system is still strong; early diagnosis improves long-term survival rates; knowledge of one's hiv status helps in prevention of hiv transmission to one's sexual partners, foetuses, babies, caregivers and other; knowledge of one's hiv status prevents re-infections, and; a positive test even for those who have been diagnosed later means one can still have access to life-saving treatment (st maarten aids foundation 2003) . put differently, 'an hiv test opens the door to accesing a range of hiv prevention options available depending on a person's hiv status to keep themselves and their loved ones hiv-negative' (unaids n.d.) . hiv testing is indeed critical as an entry point for hiv treatment and care. 5 unaids 4 one of the principles of the fast-track approach also calls for change; that is, among other things, stopping what does not work when it comes to the hiv response 'and scaling-up proven programmes' (unaids 2015, p. 6). 5 'hiv testing services (hts) are the entry point for diagnosis and access to life-saving antiretroviral therapy (art). early diagnosis and initiation of art have been shown to drastically decrease viral load, which reduces individual morbidity and mortality, and limits onward hiv transmission. hts can also offer a pathway for primary prevention interventions, including programs that deliver pre-exposure prophylaxis, voluntary medical male circumcision, and prevention of mother-to-child transmission ' (al., 2019) . and who have confirmed that adherence to an effective art regimen can result in reduction (by 96%) of the risk of transmitting the virus to an uninfected sexual partner, and can cause viral suppression that will lead to a plhiv living a normal lifestyle and longer life expectancy. without art, plhiv develop aids as a result of a compromised immune system, thereby exposing them to development of infections, certain cancers, and other severe clinical manifestations (unaids 2016; un-desa 2017) . in this vein, i am in favour of programmes such as the 'who test and treat' policy in ssa. those countries in ssa which have already adopted and implemented this approach are therefore to be commended. the introduction of 'test and treat' programmes have significantly contributed to an increase in the number of people accessing treatment (skovdal et al. 2016; avert, 2019a, b; unaids, 2020a, b, c) . ssa governments can alocate money, including requesting for hiv programmes funding from international donors, purchase mobile clinics and hire testing community workers to go door-to-door in communities and educate people about hiv prevention and the importance of hiv testing to an individual and common good, and then offer counselling and on-the-spot hiv testing and art initiation whenever individuals consent (egpaf 2017; sulat et al. 2018; silberner 2019) . this should be done in combination with routine hiv testing in healthcare facilities. without further delay, before the preparation of this article, i was aware that issues surrounding personal autonomy in hiv testing are multifaceted -therefore they cannot be all explored in this article. thus, the scope of this article is limited. firstly i have not explored various cultural conceptions of autonomy in this article (for such see the position of, mbiti 1970; gaylin and jennings 2003; woods 2002 woods -2004 traphagan 2013; song 2018) who have suggested that the primacy of the value of autonomy has its roots in western liberalism (particularly american). i have only mentioned in passing the ssa traditional ontological outlook and its potential impact on hiv healthcare ethics. secondly, the scope of the present review does not include a review of issues surrounding autonomy in clinical practice, including whether it is even possible to actualise informed consent requirements in medical practice (for this see, the position of manson and o'neill 2007) . thirdly, i have not explored in detail issues surrounding personal autonomy, hiv stigma and discrimination, and hence, some may argue, the importance of personal autonomy in healthcare practice. i am persuaded that the subject area of stigma versus personal autonomy deserves a critical exploratory article of its own. nonetheless, i have written this article having bourne in mind existing study findings and reports on stigma and discrimination (april 2009; stangl and grossman 2013) , 6 which, by implication, indicate that humans are social beings affected by the social environment. extensive studies that have found that fear for hiv stigma compromise hiv testing uptake and/or art adherence are also arguably an indictment on how respect to personal autonomy in hiv healthcare should be viewed. if indeed humans are self-rulers and rational players, why should social stigma prevent them from making self-rational and moral decisions in directing their own hiv medical therapy for their own good, and direct their lives as they deem fit? why should patients be declared and imputed with personal autonomy and yet at the same time blame the impact of social stigma on preventing potential hiv service-users from seeking medical attention? is this not conceptually and practically conflicting? and lastly, this paper does not explore whether the approach to hiv testing and treatment should be different from how we approach cancer, malaria, tuberculosis, covid-19, etc., even in light of hiv treatment universal health coverage. for my positions on this, i agree with hiv exceptionalism conclusions that criticise the subjectivism tendency to separate hiv response approaches from broader health systems (de cock and johnson 1998; april 2009; oppenheimer and bayer 2009; smith and whiteside 2010; benton 2015) . i agree that hiv exceptionalism was necessary before access to and effective art was made available in ssa. indeed, the hiv exceptionalism force is losing its original power as hiv has become less threatening (smith and whiteside 2010) due to accessible and effective hiv medication-treatment which has now been made available for the majority of affected populations in ssa. 'through the combined efforts of people living with hiv, national public health programmes, global donors and a broad community 6 basing autonomy on guarding against stigma can be problematic. among other things, april (2009) arguing for opt-out hiv testing versus the issue of stigma noted: 'under an opt-in programme, ….[a person] remains oblivious of her infection and avoids any immediate repercussions from her community. yet, this only delays the consequences -she will inevitably progress to aids. in societies with high hiv prevalence, as in much of sub-saharan africa, it is all but certain that her community will find out the cause of her suffering. it will be precisely at the time of her greatest physical ailing and need for emotional support that she will suffer the burden of hiv stigma and discrimination. in the case of an opt-out programme, although her decision to test may not have been borne of her own initiative, her decision not to decline testing will empower her to control the circumstances of her disclosure and formulate a plan for addressing her disease'. of stakeholders, the number of people on antiretroviral therapy (art) rose rapidly across ssa, going from about 100,000 in 2004 to 15.4 million by the end of 2017' (nash et al. 2018, p. 1). 7 hence, almost all countries in ssa have adopted hiv national policies to treat all persons, regardless of cd4 cell count (ssa has an hiv prevalence of 25.7 million people) (nash et al. 2018) . the massive expansion of art treatment in ssa has continued to save millions of lives, hence a need to even advance more appropriate hiv testing ethics. the scope of this article therefore concerns itself with a review whether a person who can test for hiv and have access to art is an autonomous patient who should be encouraged to choose her own medical therepy for her own good. the chief aim of this article is to show by reviewing procedural, substantive, ontological and socio-relational autonomy theories that capacity or achievement of autonomy in human society is an illusion, strictly speaking. thus, premising informed consent requirements of hiv testing testing on personal autonomy is problematic, philosophically and ethically. i have demonstrated that since humans don't exist in a vacuum, but are born into society and live in families and communities with fellow human beings, the promotion of primacy of personal autonomy over the common good 8 is inappropriate. the value of autonomy has been recognised as the core of medical ethics and has been validated by court judgments as a primary good in a free society (faden and beauchamp 1986; planned parenthood v. casey 1992; airedale nhs trust v. bland 1993; c v minister of correctional services 1996; lewanika v. frederick chiluba 1998; huri -laws v. nigeria 2000; diau v botswana building society 2003; southern africa litigation centre 2012) . for example, emphasising its primacy, the south african high court even held that '[i]t is, in principle, wholly irrelevant that [the patient's] attitude is, in the eyes of the entire medical profession, grossly unreasonable, because her rights of bodily integrity and autonomous moral agency entitle her to refuse medical treatment' (castell v. de greef 1994) . compounding this, the worldwide media through television dramas and documentaries foster this perception that individual choices or wishes are/ought to be sovereign in medical decision-making (english et al. 2006) . the individual or health service-user's medical judgment is celebrated as a right to be make one's own decisions for one's own health, body and life (southern africa litigation centre 2012). the individual is held to be a master of her own body and destiny, and is free to resist any violations to her autonomy (diau v. botswana building society 2003) against others of whom she lives with in society. behind the promoted freedom, autonomy, choice, and personal rights now stands a particular vision of what is entailed in being a human being; social relationships and arrangements are only recognised as far as they are able to nurture the atomistic self (gaylin 1996) . and behind this vocabulary of a sovereign human being is the belief that human behaviour is voluntarily chosen, and that other people's conduct can be modified through rational argument (gaylin 1996; gaylin and jennings 2003) . the case of the covid-19 crisis shows otherwise. 9 my article interrogates the personal autonomy arguments and reaches a conclusion that the philosophy surrounding the value is problematic, as well as, it is silent on the ethics of the actual implications of an autonomous decision in hiv testing (selemogo 2010) . this article is, therefore, composed of three themed sections. it begins by giving a brief overview of the origin of the word 'autonomy' and its evolution, and its relationship to informed consent in healthcare ethics. the second section analyses the various conceptions of autonomy. thirdly, an alternative conception of autonomy is reviewed and advanced (a review of whether autonomy is social as opposed to individual). the paper concludes by referencing the implication of a social view of autonomy on hiv testing in ssa where hiv is an epidemic. jones (2020) more 9 in discussing the impact of the coronavirus crisis, tobias jones observes: 'it has been fascinating to see the speed at which other attitudes have changed. the indignation expressed towards people not respecting social distancing (from those who would never normally describe themselves as moralists) has been understandably shrill: here too we've suddenly realised that the wellbeing of the group is endangered by indifferent individuals, and that community -for which we've yearned for so long -means originally simply a pooling of duties…. [t]he philosopher and activist simone weil wrote that "the notion of obligations comes before that of rights. it's a complicated, but convincing case, and it seems to me that in the last month there has been a radical shift in the balance between rights and responsibilities that has changed the timbre of our lives. i've never seen so many news items about applause, or so many social media posts accompanied by clappy emojis. before, "in the absence of adversity", the psychiatrist and philosopher iain mcgilchrist said this month: "we grew flabby, selfish. we manufactured grievances that now can be seen for what they were." now, when people meet their obligations to us we're obliged' (jones 2020) . 7 in east and southern africa, 67% of adults and 62% of children living with hiv are on art (avert 2019a, b) . 8 in this article, i have used the word 'common good' to mean 'the sum of those conditions of social life which allow social groups and their individual members relatively thorough and ready access to their own fulfillment' (velasquez et al. 2014 ). the ' "common good" refers to those facilities-whether material, cultural or institutional-that' individual 'members of a community provide to all members in order to fulfill a relational obligation they all have to care for certain interests that they have in common' (hussain 2018) . and as john finnis held, 'respect for human rights is a requirement of justice and that "the maintenance of human rights is a fundamental component of the common good"' (finnis 1980 , cited in hussain 2018 recently argued that what the coronavirus public health responses worldwide have shown us is that 'wellbeing isn't individual but social', and that humans 'are not actually independent at all'. the origin of autonomy, its relationship with informed consent, and hiv testing in ssa jackson (2013) explains that the word autonomy is from the greek words autos (self) and nomos (rule), which originally was used to refer to cities' independent self-rule. 10 feinberg (1986) , among others, also have noted that the word has a greek origin which comes from the greek for 'self' and 'law', meaning the making of one's own laws. in tracing the roots of personal autonomy, taylor (2005) suggests that individual self-authorship has its roots in the romantic liberalism of john stuart mill (2015) , in which free development of individuality was promoted. feinberg (1986) states that personal autonomy has interrelated meanings, from one's capacity to govern oneself, to the sovereign authority to govern oneself. o'neill (2003) provides that the original view of autonomy in antiquity-meaning self-legislation-never referred to persons, but to property. that is, ancient autonomous citystates made their own laws, colonies being given laws by the colonising parent cities (o'neill 2003, p. 3) . so, unlike its original cities' self-rule application, autonomy has now been extended to indicate the self-governance of rational independent individuals. this extension to an autonomous human has been adopted in medical ethics, and universalised, incuding in ssa. patient autonomy is promoted through informed consent requirements. informed consent has become one of the fundamental principles in medical ethics and law (dhai 2008) . individuals are held to have inviolable bodily and psychological integrity. this body-mind integrity right is violated when a patient is afforded medical intervention: without informing her in a language she understands the nature of the therapy; she has not been told about associated benefits and risks; available options in respect to an intervention have not been disclosed, and; she has not been informed that she has a right to refuse (mcquoid-mason 2008) . unlawful medical interventions that do not respect patient autonomy can constitute assault at law (dove et al. 2017) . in common law, free and informed consent means an inclusive recognition and respect of a: patient's capacity (and competence) to consent; disclosure of information to a patient related to the nature and extent of risks incident to a medical intervention; patient understands risks involved; patient is informed about available medical options, and; patient voluntariliy consents to (or to refuse) a medical intervention (beyleveld and brownsword 2007; mcquoid-mason 2008) . put differently, the legal and ethical elements of informed consent are: capacity; disclosure; understanding, and; voluntariness (dhai 2008) . a healthcare professional who by commission or omission fails to respect these requirements may be held responsible for any injury resulting therefrom. in this vein, '[t]he traditional hippocratic belief that one could do almost anything on a patient as long as the principles of beneficence (best interests) and nonmaleficence (no harm) were upheld has been considerably' stamped by rational and moral individuals whose autonomous actions or choices take precedence (dhai 2008, p. 27) . the principle of informed consent in clinical practice is primarily a negative right of non-interference (schermer 2002; clarke 2009) . '[i]t is closely connected to a particularly western, post-enlightenment idea that an adult person is a bounded individual who is able to live her life freely in accordance with her self-chosen plan, and ideally independently from controlling influences' (dove et al. 2017, p. 150) . its underpinnings can be traced to the influential kantian and millan conceptions of autonomy-or humans as rational self-legislators who are ends in themselves (selemogo 2010) . thus, 'in the domain of western biomedicine, the epitome of personal autonomy is a patient expressing a decision that she has come to autonomously and independently' (dove et al. 2017, p. 150) . to this effect, potential hiv service-users are told that they have the right to 'make choices that meet with their own interests according to their own will…[because humans have] capacity to understand substantial information, form a judgment according to their own values and communicate with the physician freely about their wishes' (song 2018, p. 296) . in this article, i have not questioned the importance of informed consent in healthcare conduct, and in hiv testing in particular. what i question is the premising of informed consent requirements on personal autonomy. i hold that grounding informed consent on autonomy distracts attention from observable human reality-which is that there are various important aspects of and factors in life that obstruct and pose challenges to realisation of personal autonomy in society. thus, instead of promoting personal autonomy, i advance a promotion of greater cooperation between patient, healthcare professional and one'a family and community. beauchamp and childress' definition of an autonomous patient who has freedom from controlling influences is mistaken. different schools of thought have advanced various conceptions of what autonomy means. o'neill (2003) has enumerated such definitions: dignity, integrity, individuality, independence, responsibility and self-knowledge; liberty; self-assertion; knowledge of one's interests; freedom from obligations; absence of external causation; choosing one's own moral position and accepting responsibility for one's own choices; self-mastery, voluntariness; privacy; and choosing freely. in the following review, much reference has therefore been made to killmister's (2013) thoughts on autonomy because the author identifies critical aspects of autonomy that have been overlooked in various theses by celebrated luminaries. killmister's structure and analysis of the subject matter is instructive for the present review. hence, the current analysis will be restricted to a critical review of feminist accounts; kantian accounts of autonomy which have been embraced by a number of feminist thinkers will therefore be reviewed. although feminists reject kantian and rawlsian notions of autonomy due to the former's argument that autonomy is relational, there are still different theses within the feminist school of thought which are arguably similar to kantian conceptions-the only major difference being that such feminist scholars advance a relational account of autonomy due to their rejection of self-sufficiency of human beings. besides marina oshana's socio-relational theory being arguably a more persuasive feminist account of autonomy, other accounts arguably embrace kantian and rawlsian rational choice theories. i commence by considering the reflective or historic endorsement accounts of frankfurt (1988) , dworkin (1988) and christman (2009) . the theses of these great thinkers indicate that an individual's capacity for autonomy lies in her psychological dispositions. nonetheless, christman's reflective endorsement theory has been credited as an account that is placed to address the problem of socialisation-it is argued that his theory overcomes the inadequacies identified in procedural models such as those of dworkin (1988) and frankfurt (killmister 2013) . in fact, christman has argued that gerald dworkin and harry frankfurt's first and second-order desire theories overlook the autonomycompromising nature of manipulation. being autonomous, according to dworkin and frankfurt, is synonymous with a capacity to critically evaluate firstorder values, desires and preferences by referencing them to one's second-order preferences, values, and desires. thus, one's capacity 'to accept or attempt to change these in light of higher-order preferences and values' makes one autonomous (dworkin 1988, p. 20) . 11 it is held that by exercising such a capacity under second-order desires, persons define their nature, give meaning and coherence to their lives, and take responsibility for the kind of person they are (dworkin 1988, p. 20) . under this theory, second-order values ought to take priority over first-order ones; second-order values are considered to be an individual's realm of autonomous decision-making. i wish to argue that dworkin and frankfurt's second-order accounts are philosophically and, consequently, morally problematic. philosophically, this rational thesis of autonomy fails to convincingly account for the problem of socialisation of values, desires and preferences, internalisations of which compromise second-order values. a person's socalled second-order desires can be a product of socialisation. effective manipulation can reach all the way to second-order desires. thus, indeed 'to judge as autonomous individuals who are hypnotized, brain-washed, or otherwise manipulated into developing second-order desires…is to misunderstand the very nature of autonomy' (killmister 2013, p. 98 ). holton has illustrated: 'to see this [philosophical problem of second-order thesis], suppose that i implanted a second order desire in you by hypnosis… then surely you wouldn't have free will if you got your desires to conform to that; but frankfurt's account seems to have the consequence that you would' (holton 2003, p. 2) . 11 'a first order desire is a desire for anything other than a desire; a second order desire is a desire for a desire. so, for instance, you might have a first order desire to smoke a cigarette; and a second order desire that you desire not to smoke a cigarette… thus [another example], i might wish that i wanted to give all money to charity, since i might think that having such a desire would show me to be an excellent person; but i might nonetheless not actually want that desire to be effective… but when a person does want the first order desire to be effective, when they want it to be their will, frankfurt calls this a second order volition' (holton 2003, p. 1) . it can be inferred from this thesis that a person can act autonomously through identification with second-order desires. that is, a person is seen to have autonomy in so far as she has second order volitions and can bring her first order desires into line with second order volitions or desires. thus, according to this account, dogs and children don't have autonomy because they lack second-order desires or volitions (holton 2003) . they don't have autonomous second-order desires which can be used to control first-order desires. first order values can, for example, be values which form the edifice of a given moral system. thus, common good morality can be situated in first-order values (ockham's beard 2010) . frankfurtian and dworkinian accounts possess a great potential to declare someone who is acting on internalised values to be autonomous. such accounts seem to neglect the fact that external conditions (in the form of, e.g., societal rewards and punishments, and limiting human biological factors) have a tendency to make humans conform to certain behaviours (gaylin and jennings 2003) . this can be seen in the present case of coronavirus where, due to fear of receiving fines or fear of being viewed as social deviant, among other reasons, people who would otherwise wish to open their entertainment venues, go to clubs, restaurants, bars and other social facilities, or go on holidays cannot now do so. internalised first-order desires have consequences on second-order desires. internalised ideas, fears, and values which we later mistakenly come to identify as our own have inescapable consequences on our daily choices or preferences (lanier and henry 2010) . 12 a good example of internalised preference can be inferred from the 18-year-old student theorised by benson (1991) . benson explores the case of an 18-year-old whom through internationalisation of the hollywood idea that appearance is a criterion of self-worth ends up regarding beauty and fashion as essential for her self-worth. first and second-order autonomy accounts fail to explain away this lived social reality. although it is possible to hold individuals to have acted autonomously by virtue of fulfilling frankfurtian or dworkinian first and second-order requirements, it can also be argued that morally this thesis of autonomy may be amoral because it has the potential to ignore that well-being can only be achieved when both individuals and others in society act responsibly towards each other. the common good values which sustain and advance the well-being of society can be denigrated through such outlooks, and the consequences of this would be the annihilation of millions of human beings and the end of human civilisation as we know it, as each individual acts according to their own second-order values. what about christman's theory of autonomy which killmister claims is more persuasive? does christman, who criticises frankfurtian theories of autonomy, provide a more realistic perspective? according to christman's view, for an individual to claim autonomy 'necessary endorsement must be directed at the process of desire-formation, rather than the desire itself' (christman 2009; killmister 2013, p. 98 ). christman's theory of autonomy to me is equally an internalist or rational theory of autonomy. stoljar explains: for christman, preferences or desires will be nonautonomous only if they fail either a competence condition or a hypothetical reflection condition. competency corresponds to the capacity of the agent to form effective intentions relative to a desire as well as to reflect critically about the desire. the hypothetical reflection condition employs the notion of non-alienation to characterize authenticity and hence autonomy. (stoljar 2014, p. 235 ). killmister has illustrated and differentiated christman's account from other procedural accounts of autonomy as follows: for instance, we can take an individual who desires to eat a slice of cheesecake. rather than asking, as dworkin and frankfurt would, whether the individual desires to desire to eat a slice of cheesecake, christman asks how she would feel about her desire, were she to be aware of how the desire were formed. if the desire were implanted by a hypnotist, and knowledge of this process caused the individual to feel alienated from the desire, then that desire [according to christman] would not be autonomous. (killmister 2013, p. 98 ). for christman, for an action to be autonomous the individual must personally identify with the desire through a feeling of non-alienation. like frankfurtian and dworkinian visions of autonomy, i wish to argue that christman's endorsement account is unpersuasive. endorsement accounts of autonomy fail to account for internalisation of norms, values which an individual may mistakenly endorse or identify to be her own. indeed, the problem with christman's theory is not the 'inclusion of a historical version of reflective endorse-ment…, but rather that this condition is insufficient to determine the autonomy of an individual' (killmister, 2013 p. 100 ). christman's hypothetical reflection account fails to appreciate that due to deeply ingrained traditional values, imparted through oppressive (and i add non-oppressive) ideological socialisation over many years of one's life, individuals can identify with deformed desires and not feel alienated (stoljar 2014) . effects of ideological socialisation and environmental changes can cause one to treat stereotypes and acquired feelings as natural to oneself and thus formulate one's desires and plans based on such ingrained nonautonomous desires (gaylin and jennings 2003) . recipients of socialised ideologies 'are unlikely to experience alienation from either the 12 'one of the more astonishing features of current political debates on autonomy and coercion is the naïve underlying assumption about rationality and human motivation. psychology -whether based on behaviourism or on its diametric opposite and antagonist, freudianism (or any of the splinter of these two dominant branches) -views few pieces of human conduct as rational choices selected at the moment. rather, modern motivational psychology tends to see most human behaviour as being "conditioned" or "unconsciously determined," a consequence or product of life experiences that tend to make responses to certain stimuli automatic and unchosen…' (gaylin and jennings 2003, pp. 16-17) . norms that they have internalized or the preferences formed on the basis of the norms' (stoljar 2014, p. 235 ). mele's (1995) external historical account is a hypothetical counter-example to procedural accounts (killmister 2013 ). mele dismisses psychological (internalistic) accounts of autonomy (christman 1999) as insufficient. he advances that, if all individual human beings were like athena or a god, procedural accounts of autonomy would indeed capture what amounts to autonomy, and therefore his (mele's) historical account of autonomy would be unnecessary. however, because humans are not athenas, he argues that his alternative account is therefore valid or convincing and necessary (mele 1995) . i actually find mele's account of autonomy more persuasive than frankfurt, dworkin and christman's accounts put together. for mele, for an agent to be autonomous her actions must not be compelled by another: it is a historical property of agents required for responsibility for the possession of a pro-attitude. a necessary condition of an agent s's authentically possessing a pro-attitude p (e.g., a value or preference) that he has over an interval t is that it be false that s's having p over that interval is, as i will say, compelled -where compulsion is not arranged by s. (mele 1995, p. 166 ). the implication of mele's theory is that pro-attitudes can violate an individual's autonomy. to this effect, mele's theory implies that second-order desires (explained above) must not be a product of pro-attitudes or compulsion. he predicates his theory on an understanding that humans are susceptible to acting on socialised values (compelled or instilled pro-attitudes 13 ). according to mele, compelled pro-attitudes, therefore, make individuals non-autonomous (mele 1995) . put differently, an agent's choices are nonautonomous, according to mele's exposition, when: an agent comes to have a pro-attitude because of an external force, rather than via exercise of her skills for critical reflection and evaluative judgment; (ii) the instilled pro-attitude is one she is unable (in the absence of radical counterfactuals) to eradicate or attenuate; (iii) she did not arrange the by-passing herself; and (iv) she does not, nor did she earlier, possess other pro-attitudes that would support her endorsing the instilled pro-attitude. (killmister 2013, p. 101) the implication of this understanding of autonomy is that human motivation is susceptible to socialised pro-attitudes that are difficult to efface. mele's exposition of autonomy makes more sense as it touches on external factors that internalist accounts of autonomy fail to account for. indeed, a fully competent individual who is able or capable of acting rationally upon desires (values which she has critically reflected upon) cannot necessarily by this very token be safely considered autonomous, as the pro-attitudes (which she considers to be her own) could have been socialised earlier in life. however, i do not completely agree with mele's thesis regarding what he then advances as constituting autonomy. this disagreement lies in mele's advancement of an alternative theory of self-control as being a mechanism through which one can achieve autonomy. this theory (capacity for autonomy by virtue of self-control) appears to water down the fact that both inculcated cognitive biases and environmental changes can compose the very mechanics of self-control. 14 mele's self-control theory does not satisfactorily explain how the problem of socialisation of pro-attitudes acquired since childhood can be qualified in the assessment of what amounts to one's autonomous self-control. studies have established that babies do not have competent mental capacities for reflection during early childhood-a period when they acquire pro-attitudes. 15 killmister has argued that there is a problem in mele's theory if it is to be used as a guide for identifying 'autonomy-inhibiting socialization' (killmister 2013, p. 101 ). mele's approach would rule out most early childhood education directed at developing the very necessary mental capacities. killmister postulates that 'if the relevant capacities are inoperative or not yet developed, as they will be in very young children, mele takes them to have been bypassed' (killmister 2013, p. 70) . 13 a pro-attitude is a person's mental attitude (a feeling or opinion about someone or something) directed toward an action under a certain description; pro-attitudes may include moral views, desires, urges, aesthetic principles and economic prejudices (bunnin and yu 2004) . 14 despite an individual 'being perfectly able to appraise critically and act upon her desires and values, the perfectly self-controlled person may nevertheless be acting on desires and values that have been implanted into her by artificial means, ones whose development has bypassed normal reflection and awareness' (christman 1999, p. 96) . 15 'human beings are born biologically premature, so that unlike most mammals, many of our neurological and physical functions and all of our behavioral capacities exist at birth in potential form only. to come to fruition, these potentials must be molded by a social environment' (gaylin and jennings 2003, p. 34) . the conditions which influence our everyday adult conduct are set by our parents and culture early in life through a conflation of coercion, parental encouragement, emotional intimidation, conditioning, and other mechanisms (gaylin and jennings 2003 ). mele has nonetheless acknowledged that bypassing is common in infants but argues that such bypassing is not sufficient for compulsion unless the pro-attitude is also practically non-sheddable. to this, killmister has responded that many people have pro-attitudes (traceable to early childhood socialisation) that they are practically unable to shed. she claims that even our attitudes towards evidence, reason, and reflection are both presumably inculcated and nearly unsheddable: the problem here is that one of the central roles of socialisation is to inculcate the very pro-attitudes that are required for the kind of self-control mele sees as necessary for autonomy. to be self-controlled is to believe and desire on the basis of an assessment of evidence. this will rely upon having the appropriate pro-attitudes towards evidence and reasons, which must at some point have been instilled in the child. (killmister 2013, p. 102) . in our early development each of us is subjected to physical and social forces of which we are largely ignorant, over which we have no control, yet from which we acquire values, beliefs, motivations, and capacities for rational evaluation that subsequently guide our choices and actions. these forces "destroyed" any capacity to become a different sort of person with selfcontrol regarding any unsheddable pro-attitude that we happen to have. consequently, every unsheddable proattitude is compelled, and anyone with firm unshakeable principles of action ends up being inauthentic and non-autonomous. (kapitan 2000, p. 89 ). stoljar rejects procedural approaches to autonomy by replacing them with a substantive account (stoljar 2000 (stoljar , 2014 . she argues that procedural conceptions fail to appreciate that people who have been subjected to false and oppressive internalised norms cannot be autonomous. according to her thesis, oppressive socialisation can lead an individual to internalise false beliefs which the victim may later come to endorse as her own. decisions made on the basis of internalised false beliefs are therefore not autonomous, she declares. stoljar's thesis indicates that mere possession of false/ oppressive beliefs makes an individual non-autonomous. i wish to agree with killmister's observation that stoljar's theory is initially promising as it acknowledges that 'the question for all theories is what kinds of socialisation are incompatible with autonomy' (killmister 2013, p. 104) . i, however, find stoljar's account unpersuasive. what is problematic about stoljar's theory is that it reduces autonomy to an individual who is free from false/ oppressive socialisation (killmister 2013) . such a perspective fails to consider that for an individual to be autonomous she does not only necessarily need to choose her own moral position but also enjoys the absence of any form of external influences on her self-determination capacity. that an autonomous individual is a self-ruler, or a law unto herself, no matter what form of socialisation she underwent, should not be ignored. an autonomous individual freely acts in accordance with a self-chosen plan by virtue of self-law and/ or morality (kant 1785; gaylin and jennings 2003) . what the preceding arguments entail is that even nonoppressive internalised norms can still be non-autonomous, provided they were instilled or regulated by another or something external to the individual claiming autonomy. if to be autonomous is to be self-governing or self-directing or, in other words, to act on motives, values, and reasons that are one's own, then how can we restrict non-autonomous action to only false/oppressive socialisation? moreover, the fact that the person who is supposed to be a law unto herself is at the mercy of false/oppressive socialisation shows a lack of sovereignty, like that of the christian god, hence the illusion of autonomy. the dialogical theses by westlund (2009) and benson (2011) view a person to be a social self. according to these accounts, a person's answerability to others becomes the key condition for autonomy. in other words, autonomy is synonymous with a person's ability to have normative power or authority over one's decisions (mackenzie 2008) . autonomy thus becomes dispositional. what is encouraging about dialogical approaches is that they indicate that human beings are interconnected-in other words, social selves. as will be shown below, however, the thesis of dispositional autonomy is unconvincing because this theory propounds that a capacity for autonomy is premised on an individual's mental capacity. westlund argues that autonomy should not be understood in terms of an individual's psychology or history; rather it is constituted by a particular kind of disposition. her theory suggests that an agent's answerability to others is a key condition for autonomy. she rejects psychological accounts which designate an autonomous agent as one who critically reflects in an appropriate way in evaluating one's preferences, desires and motives. in other words, westlund rejects rational choice accounts of autonomy because such theories merely argue that autonomy is achieved when an individual engages in critical reflection or if an individual acts or chooses to act in accordance with desires which she has self-reflectively endorsed (friedman 2003; christman 2009 ). according to westlund, one's autonomy is instead undermined if one is unable to give reasons in defence for one's actions or choices (westlund 2009; killmister 2013) . so, an individual who readily answers for herself constitutes a self-governor or autonomous person, she suggests. according to benson, an autonomous act is achieved when a selfregarding attitude is expressed in one's willingness to take responsibility for one's actions (benson 2011) . in this case, if an agent claims authority over her own actions, then such an agent can be considered autonomous. these accounts suggest that certain emotional states and attitudes towards oneself are necessary conditions for autonomy. such approaches appear to require that reliance on critical reflection and judgment for autonomy is only possible if a person can endure criticism of her own sense of basic competence and worth. i wish to state that dialogical accounts of autonomy are philosophically and morally problematic. they are philosophically unpersuasive because such approaches ground autonomy on a person's ability to offer reasons for her choices. and these accounts are morally problematic because they are individualistic in outlook-such outlooks appear to promote autonomy on the basis of meeting moral obligations to self. 16 although westlund criticises psychological accounts of autonomy, i wish to argue that dialogical accounts of autonomy are equally psychological or internalist in substance. thus, the criticisms of rational choice accounts of autonomy can to a larger degree equally be applied to dialogical ones; both approaches clearly ignore or brush aside the reality of socialisation and environmental conditioning. kantian psychological or rational conceptions of autonomy often erroneously portray agents as causally and psychologically independent of environmental conditioning. westlund regards someone as non-autonomous if they defer to something or someone rather than providing their own reasons in choice-making; however, she appears to ignore the fact that defending a choice with plausible reasons is not necessarily synonymous with being its author, or authentically identifying or individually valuing a given choice. an agent can defend, for example, oppressive values, not because that is what the agent desires, but because it is required. external circumstances can cause an agent to embrace oppressive values and yet still be in a position to stand behind a given decision as their own. thus, being answerable to one's choices or behaviour does not make one autonomous, but potentially makes one accountable to socialised values which one's external environment through interpersonal and environmental conditions have imposed upon or inculcated into the agent who is claiming autonomy. a person can give a convincing or persuasive reasoned answer to something not because she necessarily has chosen the value and identifies with it, but because of environmental conditioning and limitations. an agent is capable of defending inculcated or internalised oppressive values through adaptive preference formation (elster 2016) . 17 expressed differently, the problem with westlund and benson's conception of autonomy is that individuals can stand behind decisions or actions which are paradigmatically non-autonomous. this is especially true seeing that it is widely accepted that 'we humans are very good at inventing post-facto explanations of our actions, even to ourselves' (moll 2004 , cited in killmister 2013 . killmister (2013) concludes by suggesting that we do not have absolute autonomy, but 'degrees of autonomy'. i hesitantly agree! one agrees in a strict sense that 'degrees of autonomy' can be in the form of restricted autonomies in which individuals have been placed under laws where boundaries have been drawn on how far they can conduct themselves. one may as well call this 'permitted autonomy'. it is within the boundaries of laws (natural or positive), ethics, regulations and conventions where one can agree that 'degrees of autonomy' are apparently found. thus, yes, we humans have no absolute autonomy. for example, the current covid-19 lockdown and social distancing rules indicate that human autonomy is not absolute. being the law unto oneself is limited to what governments proclaim are boundaries within which individuals can be allowed to rule themselves. however, founding autonomy on limited or relative autonomy also crumbles when the whole picture of human motivations, in light of the ever-changing environment, is closely examined. thus, can killmister convincingly enumerate in what circumstances exactly an agent can enjoy this limited autonomy, circumstances which are excluded from the susceptibility to socialisation, internalisation, biological influences or environmental changes? gaylin (1996) has established that human motivation and behaviour is highly susceptible to environmental influences. therefore, he argues that protagonists of autonomy are mistaken in believing that human behaviour is voluntary. gaylin submits that present behaviour is moreover significantly determined by past treatment (gaylin 1996) . he suggests that human behaviour is less rational than we are willing to admit. he advances that our behaviours are influenced by our emotions, which are usually more effective than logical argument, and adds that shame, fear, guilt, greed and pride influence human behaviour. the implication of this analysis is that a combination of societal morality (morality which can be internalised through effective socialisation), the institution of law in society which defines the boundaries of human behaviour, and human natural susceptibility to emotions (as drivers of decisions) makes the argument for capacity for individual autonomy, even in limited circumstances, problematic. discussing the stifling nature of our biological make-up on human decision-making, morison (1984) has observed that besides historical influences human 'agency' is encumbered with genetic or environmental factors which subtly motivate our day-to-day choices. for morison, much of our human behaviour is significantly influenced by events over which we as individual have little or no control. he quotes melvin konner's the tangled wing: biological constraints on the human spirit (1982) 18 work as an extraordinary book which identifies, among others, the roles genes and the environment play towards behaviours and choice: it requires only a little reflection to realise… that our choice is strictly limited to the possibilities displayed before our conscious in real time including those we can call up from memory or create by synthesizing bits and pieces of previous experience… not nearly so clear is the degree to which the final choice is also so conditioned or "shaped" by genetic patterning or by previous experience of which we are no longer conscious. my hunch is that such influences are much more numerous than we imagine and that autonomy in any strict sense is an illusion. (morison 1984, p. 46 ). my review of autonomy so far agrees with feminist relational accounts to the extent that feminists generally highlight 'that agency cannot be separated from interdependence, since large swaths of our lives, especially during the formative years, are spent dependent on others, and those relationships function to inform our preferences, our values, and our understanding of our selves' (wenner 2020) . hence, i have contended above that autonomy cannot be conceptually explained without convincingly explaining away the impact of human social embeddedness and environmental change on human capacity for autonomy. i have thus shown that feminists' relational account analyses are only insufficient to the degree that they theorise that humans can be autonomous by virtue of a psychological state of mind. in the following discourse, i will show that autonomy is a social phenomenon. crittenden (1993) has observed that critics of liberalism, and even some liberal theorists, have criticised the emphasis of autonomy by liberalists. indeed, internalist conceptions of autonomy are not only conceptually unconvincing, but also, since they are associated with self-sufficiency, they exude 'the worst aspects of atomistic individualism, insulation, social isolation, and an indifference to society's values and interests' (crittenden 1993) . the fact that humans are born into society, are interdependent, co-exist, and therefore have to act in solidarity for the common good is almost ignored in rational theories. humans in psychological theories of autonomy become laws and morality unto themselves. crittenden, like gaylin, acknowledges that human beings by nature are interdependent and interconnected. hence, he argues that a conception of autonomy which is premised on self-sufficiency does not represent a fulfilment of autonomy but its abandonment. he submits that autonomy has a social nature and explains that autonomy develops through sociality, and it also requires sociality for its exercise. crittenden quotes anthony arblaster, who has noted that it is not normal or even desirable for a human to be self-sufficient (arblaster 1984) . he also invokes jennifer nedelsky, who submits that 'the perfectly autonomous man is thus the most perfectly isolated' (nedelsky 1989) . for crittenden, autonomy does not entail isolation from the presence of the influence of others or a necessary rejection of societal values, but the very concept of autonomy depends on these very factors. 'the social nature of autonomy appears to undergird a communitarian notion of the self as socially situated' (crittenden 1993, p. 37) . the author argues, among other reasons, that he believes autonomy is social because humans are not born with autonomy, but that autonomy requires psychosocial development. he also argues that 'autonomy is social because we can only be autonomous when we know we are acting autonomously; and we can only know that when we give an account to others of how we arrived at a decision or action' (crittenden 1993, p. 38) . according to crittenden, the only autonomous person is one who is able to remove herself from the social matrix. he argues that since no person is born autonomous; we may 18 konner has demonstrated that man's behaviour is influenced by nature and nurture (konner 1982) . only be autonomous through socially distancing ourselves from the social matrix. he suggests that self-autonomy, provided one was born and lives in society, is impossible: any kind of introspection or reflection must be done in and through language, and the language we use is itself a cultural or social inheritance. we do not create it, and in this sense also autonomy has a social side… to make our actions and judgments intelligible to ourselves, we not only translate them into language, but also form them through language. the only language we have available by and through which to think rationally and self-reflectively, is one based on cultural tradition… there is implicit in every language, as part of that cultural tradition, a system of norms and standards that determine proper use. (crittenden 1993, p. 44 ). i agree with crittenden's theory of social autonomy, even though there are issues which arise from a further reading of his account which i do not necessarily agree with. when crittenden suggests that an autonomous person is one who is able to distance oneself from the social matrix-a matrix which one earlier identified with-this perspective appears to suggest that an individual is capable of extricating herself from the social context, and from her genetic make-up. if crittenden means that an individual can extricate herself from the environment (a reality which has made that person who she is), i argue that doing so is not possible in reality due to biological constraints, interdependence, common human frailty, and socialisation. in other words, because all human beings have internalised pro-attitudes, it is impossible for them to disown or separate themselves from what they are personally disillusioned to believe are their own personal values and aspirations, if they later on choose to live by themselves. that is, even if a person later decides to live alone, like the asocial koala which only has social intercourse with other koalas during the breeding season, that person very likely already has embedded pro-attitudes which they will inadvertently carry with them, unless they were nursed by a koala as a baby and have since lived alone in the jungle. feminist theorist marina oshana grounds autonomy on a socio-relational premise. oshana submits that autonomy is equivalent to self-governance (she states that the synonyms for self-governing are: 'free-standing', to be independent (self-sufficient), to be separate, and to be self-ruling and sovereign) (oshana 1998) . she rejects psychological conceptions of autonomy and advances an externalist account. she invokes both the internalist (psychological) and externalist (socio-relational) perspectives in her conceptualisation of what autonomy is. oshana submits that individual self-governance is in reality social. for oshana, 'autonomy is a condition of persons constituted, in large part, by external, social relations people find themselves in (or in the absence of certain social relations)' (oshana 1998, p. 81) . in this sense oshana's conception is to some extent similar to crittenden's theory. however, unlike crittenden, oshana adds that manipulation, coercion, subjection to the dominant will of others, and also 'the internal phenomena native to the individual such as captivity to desires or physical impulses, psychological neuroses, or weakness of the will' compromise the capacity for autonomy (oshana 1998, p. 83) . oshana criticises dworkinian, frankfurtian and christmanian accounts of autonomy as inadequate because these accounts are internalist. indeed, as shown above, rational accounts of autonomy premise capacity for autonomy on the 'structural and/or historical character of a person's psychological states and dispositions, and on an agent's judgments about them' (oshana 1998, p. 83) . for oshana, an individual does not become non-autonomous merely by being born in an environment where one has no control, but one becomes non-autonomous by virtue of the effects of the conditions of a given environment. she maintains that choice does not guarantee autonomy. this is because a person who may be exercising what appears to be genuine choice may be compelled to do so by others, and endorsing such choices from within does not guarantee autonomous agency (oshana 1998) . in regards to the assumption that critical reflection in a procedurally independent fashion makes one's choice an autonomous one, oshana argues that 'being able to engage in critical reflection, to take stock of oneself and to shape oneself on the basis of this evaluation, does not guarantee that whatever state of affairs ensues from this activity will be one of autonomy' because autonomy does not exclusively depend on circumstances descriptive of an individual's psychology (oshana 1998, p. 89 ). oshana has therefore advanced four conditions necessary for autonomy: critical reflection, procedural independence, access to a range of relevant options, and the condition of social-relational properties. she argues that an individual cannot be autonomous if: (i) one cannot engage in critical reflection or objective appraisal of one's motives or actions, and the environment in which one's putative values develop; (ii) if she is, in fact, influenced or restricted by others in ways that constrain autonomy (such influences can be by way of manipulation or coercion); (iii) that autonomy becomes questionable when a person claims that their decision was autonomous in circumstances where they were lacking in access to an adequate range of options; and, (iv) an individual who is in society (having relations with others) does not limit herself to relations which enable her to pursue her goals in a context of social and psychological security (oshana 1998) . she submits that these four conditions for autonomy are not mutually exclusive; they must all be satisfied for an individual to claim autonomy. for oshana, her account of autonomy has three benefits: it recognises the human condition; it recognises the status of humans as moral agents; and, that a socio-relational account of autonomy 'can easily explain how persons might be selfgoverning even when manifesting external or communal virtues that might appear to reduce autonomy' (oshana 1998, p. 98) . the socio-relational conception of autonomy is more convincing, philosophically and morally. it not only appreciates that humans are unique, but also recognises that humans are only able to exercise their uniqueness or the 'self' 19 in a socialised world encumbered by fear, emotions, the need for social validation, a changing environment, and the need to act responsibly in order to protect and promote the common good for mutual well-being and survival. ravven (2013, pp. 336-411) has shown that mounting data from history of ethics and neuroscience demonstrate that a human being is in reality the 'i that is we'. she states that neurobiological and other evidence have shown that the body-mind boundaries ethics celebrated as inviolable by millan and kantian ontological theses are mistaken. ravven demonstrates that the dimension of the human self extend beyond the scope of the body-mind, and that human investment in others in the world is finally what ethics is all about, and should be acknowledged as such. we are made for togetherness. throughout, her analysis, she convincingly demonstrates how locating the self as distributed beyond our skins and brains can provide a more plausible and appropropriate ethical and moral approach to hiv testing decisionmaking ethics. for ravven, 'the scope of the self as a moral agent, of who is performing a given moral action, can be distributed beyond the individual to groups, and even extend at times to whole contexts'. this indicates that hiv testing decision-making is in reality complex. firstly, by citing the work of clark (2009), ravven has demonstrated that the self as we understand it is joined to society and is one with the world. this is in contrast to individualised informed consent requirements which advance a self self. according to clark (2009), reported by ravven, 'at least some aspects of human cognition… [are] realised by the ongoing work of the body and/or the extraorganismic environment,' so that the 'physical mechanisms of the mind… are not all in the head' or in other central nervous system. ' ravven explains that our attraction to selfhood fails to account for an observable reality that demonstrates that as humans we are not 'locked-in' agents-as beings whose minds and physical abilities are fixed quantities apt (at best) for mere support and scaffolding by…[our] best tools and technologies.' instead, 'our minds and bodies are essentially open to episodes of deep and transformative restructuring in which new equipment (both physical and 'mental') can become quite literally incorporated into the thinking and acting systems that we identify as our own minds and bodies.' she emphasises and advances that humans do not only discover the world within their selves, but also discover themselves as parts of it. this entails that humans ought not to conceive themselves as the whole story of the whole, but as part of the story that makes the whole story complete. this outlook is similar to ssa ontological perspective that situate a human as 'a part of the organic whole' (mbiti 1970; menkiti 1984; diop 1991; tutu 1999; nussbaum 2003; woods 2002 woods -2004 molefe 2019) . therefore, an hiv testing regime that locates hiv as a shared reality will also adopt appropriate ethics and human rights that intergrate this reality. current hiv testing ethics and human rights on decision-making in ssa have not reflected this human reality (eba 2015) . secondly, ravven shows how a person is an 'i that is we' by invoking co-consciousness empirical findings that have demonstrated that 'the self as a fully aware self-aware includes perspectives that were initially 'other': third person perspectives now taken in as one's own have relocated the self outside itself and in another'. she suggests that as humans we create a shared self-a self that is both mine and yours-when we unconsciously integrate our people's values and perspectives with our first person perspectives. she therefore concludes that humans are at best relational selves who discover the self through other's eyes with whom they have a shared reality, and a shared world. ravven indicates that humans share an environment of inescapable embeddedness. thus, ethicists, including hiv policymakers in ssa, should begin to acknowledge and accept that the self cannot exist in a social vacuum. the discovery that the self is not atomistic therefore 'heralds the end of the…cherished illusion… namely the illusory goal of independence, self-sufficiency, and free autonomy' promoted in hiv testing ethics which seek to disintegrate the self from her social embeddedness: at any given time the self is constructed by a relation to another person. 'people have as many selves selves as they have significant others.' these selves emerge from the early relationships with parents, siblings, extended family members, and others who have an impact on one's life, and they profoundly affect motivation and emotions. unconsciously perceived similarity triggers the relational patterns to take hold, without our conscious awareness or even the ability to control the process… the other and the relationships are necessary for the feeling of 'me' of this 'me'… heinz koht [a psychoanalyst]… held that it is through 'expanding its selfexperience to include the whole surround' that an infant comes to be able to (1) feel itself confirmed as a self, (2) pursue its ambitions, and (3) pursues its ideals. (ravven 2013, pp. 369-370) . thirdly, describing findings from neurobiological experiments, ravven reports that research by thomas metzinger and olaf blanke have also demonstrated that the boundaries of the self transcends the boundaries of our bodies and minds: we mistake the feeling of the self as our interior, a soul-thing, a solid bounded essence that is our true self that we alone know and disclose to the world. but that is a false picture. we are more like verbs than nouns; we make parts of the world feel like the self, and we fill our feeling with our engagemnets in the world. (ravven 2013, p. 372) . fourthly, ravven turns to neurochemistry discoveries, like the one by donald w pfaff, that have also illustrated that the self transcends body-mind. and suggests that ethics should be grounded on relational autonomy: pfaff shows that the feeling of the self and where we draw the line between the self and other, self and the world, depend upon particular neurochemicals. these chemicals that produce the self-other divide, he says, are sometimes turned off, and when they are we experience others as if they were ourselves. the neurochemistry that produces the feeling of self as extending into others, he argues, underlies ethics. he says the chemicals that turn off the feeling of self-other boundary operate in fear and in love, in empathy and in aggression, and in other situations. these chemicals create a sense of shared experience and even of merger. pfaff believes that this mechanism produces ethical action by creating empathetic responses to others. (ravven, 2013, p. 373 ). the dominant, individualistic understanding of autonomy that features in' bioethics and medical ethics underpin the idea that individuals are 'in their ideal form, independent, self-interested and rational gain-maximising decision-makers' (dove et al. 2017, p. 150) . my review of autonomy in this article demonstrates that such a view is erroneous as it does not convincingly account for both external and internal (influences of biology on decision-making) environmental factors. this individualistic conception of an autonomous patient is inconsistent with lived human life-it does not capture the breadth of lived human reality that shows the 'i that is we'. conceptions of autonomy, especially in clinical practice, 'should accommodate the fact that people are rarely, if ever, fully independent individuals' (dove et al. 2017, p. 151) , hence, as an example, the challenge posed by hiv stigma to hiv testing uptake. as humans, we are social, cultural and biological beings whose decisions, including in healthcare, are shaped by a conflation of powerful social, cultural and biological forces that often times are beyond us (konner 1982; gaylin and jennings 2003; ravven 2013; sapolsky 2017) . this is the more reason why we need each other as humans: as opposed to atomising ourselves. hiv testing ethics in ssa should be premised on the human reality of a self beyond itself, as this approach captures the physiological, biological, pyschological, sociological and cultural aspects of human condition; unlike the kantian and millan conceptions of personal autonomy which are largely abstract psychological ontologies. instead of advancing abstract ethics of a self within self and unto self, ssa hiv policymakers have also something to learn from ssa traditional and moral analysis that view a person as 'a person through other persons' (mbiti 1970; menkiti 1984 )-an outlook that was developed in the light of ssa's unique experiences and lived reality, besides ontological deliberations. this ssa outlook is consistent with the conclusion of my analysis in this article that suggests that humans are incapable of being autonomous-they are social creatures who constantly, also unconsciously, simulate the values of their socio-cultural environments as their own. drawing ethics that recognise and reflect environmental impacts, including of love, empathy, fear and hate, on individual decision-making, will therefore be a good starting point for reconfiguring individualised hiv testing informed consent requirements in ssa. hiv testing policymakers in africa should cease ignoring the impact of the illusion of personal autonomy on our shared humanity. rather, they should explore their own lived experiences and reality, review studies that indicate that as human we are part of the organic whole, explore potential ethics grounded on the recognition of social attachments as evidenced in sexual and parental love, and even in friendship, resist the illusion of autonomy, and advance realistic ethics where the individualised cold isolated person is restored to who she really is: a unique part of an organic whole. 'parent love and especially motherly love, 'take the blurring of identity between two living beings to new heights,'… [ -] the upshot of all this is that the various mechanisms that induce sexual and parental attachment can be harnessed and be recruited for all kinds of prosocial behaviours and attachments' (ravven 2013, p. 375) , as opposed to surrendering hiv testing ethics to the seduction of autonomy. to this end, i wish to invite ssa hiv policymakers to consider basing hiv testing on altruism, or what ravven (2013) terms, an ethic of: 'shared selves'-'a sefiness that loses the boundaries of the skin and is extended and distributed to others'. a self who is born into society, is interdependent, interrelated, and shares with others shared human frailty and vulnerability. recognising this kind self can lead to an appropriate reconfiguration of hiv testing ethics. hiv testing ethics, in particular informed consent requirements that are now premised on personal autonomy, should reflect a human being who is unique and yet a creature of the inescapable inculcating environment that makes her the 'i that is we'. according to ssa traditional and moral thought, 'i am because we are', and 'we are because i am'. ravven states: mounting data from neurosciences show that evil is rooted in the failure to see others as ourselves. in the case of genocides such as the holocaust, it is a collective failure of society-wide proportions. the self-other boundary beyond the skin is of central importance to rethinking of ethics, to a deeper understanding of both good and evil. (ravven 2013, p. 377) personal autonomy cannot provide a sufficient and persuasive starting point for bioethics (o'neill 2002 (o'neill , 2003 , in particular hiv testing decision-making. it is necessary for ssa countries to reconfigure their healthcare ethics and place them within the overall compass of human condition, and in the light of the setting of ssa's unique socio-economic and cultural background (wood 2002 (wood -2004 ravven 2013; joseph et al. 2018) . it is appropriate to get rid of abstract liberal and libertarian concepts of an autonomous patient and reconsider the observable and lived situation of the relationship between patients and their environments. the emphasis on primacy of patient autonomy distracts attention from important aspects of life and healthcare: 'wellbeing is social'. it is crucial to eradicate the man-made autonomy versus medical intervention crisis and move towards greater cooperation. hiv testing informed consent requirements should be premised on ethics of love, honesty, empathy, sympathy, friendship, togetherness and solidarity. personal autonomy is an illusion. a review of the universalised dominant western liberal view of personal autonomy demonstrates that the general agreement that informed consent in hiv testing is required to respect personal autonomy 'and that autonomy is a basic ethical value, is more apparent than real' (manson and o'neill 2007, p. 17) . personal autonomy, strictly speaking, is an illusion. human lived experience and reality show that our lives and decisions are encumbered by combined forces of socialisation, genetics and changing external environmental factors that make the idea of an ability or capacity for autonomy resemble a fantastic dream which, when we wake up, we realise was just a dream and not something achievable in a real, civilised and striving society. in this vein, universalised ethics which continue to premise informed consent requirements in hiv testing on personal autonomy are inappropriate. human beings are not asocial or atomistic that they can be a law unto themselves; they are individuals who are enmeshed in complex social realities of reciprocity, mutual obligations, and responsibilities for amicable co-existence, well-being and survival. moreover '[h]uman behaviour is less 'voluntary' than libertarians and theorists of autonomy would have" us believe (gaylin and jennings 2003, pp. 7-8) . as indicated in the analysis, "human behaviour is less rational than most of us would like to believe it is', in that 'fear, greed, shame, guilt, and pride fuel the machinery of' our decision-making and choices (gaylin and jennings 2003, pp. 7-8) . it is these aspects which should also be acknowledged and reflected in hiv testing informed consent requirements in ssa. like what has been shown in the covid-19 pandemic response, persons living in ssa countries should be made aware that as social beings and living in complex relations with others in society, they have a duty to test for hiv because hiv is an epidemic that affect the lives of both people living with hiv and others (especially, close family members). the hiv epidemic not only affects the person living with hiv, but causes suffering, and some instances even death, to family members and people in the community. hiv testing, like the involuntary covid-19 lockdowns and social distancing, is a common good. in other words, the effects of aids are often corporately felt within the arena of the 'i that is we'-especially in the ssa setting where relational autonomy is articulated (woods 2002 (woods -2004 . in conclusion, whenever we as humans are faced with the temptation to celebrate our 'individual autonomous right', we should pause, consider, and remember that we are because of the humanity of others: our birth came through others; our name was given to us by others; we have been educated by others; the respect we demand is given by others; the first bath we had was given to us by others when we were born; our last bath will be given by others; our funeral and potentially dignified burial will be organised and conducted by others; and everything we have owned will be inherited by others once we are dead. we are simply not autonomous as individuals; we are but interdependent and interconnected social creatures. therefore, we should act in solidarity towards each other by formulating appropriate hiv testing ethics and encouraging people to test for hiv so those who need it can access appropriate therapy. the covid-19 crisis has taught us that 'wellbeing isn't individual but social' (jones 2020) . this indicates that ssa countries may not be able to achieve the sustainable development goal (sdg) 3 (united nations 2019), together with the unaids' fast-track strategy that explicitly call to end the epidemic by 2030 (unaids 2014), if hiv testing policies in ssa continue to ignore that humans are social beings (gaylin and jennings 2003) and 'wellbeing isn't individual but social' (jones 2020) . it is up to hiv policymakers in these countries to re-examine personal autonomy in hiv testing, and hopefully identify appropriate bioethics and human rights policies which are reflective of natural human condition and are suitable for the ssa socio-cultural setting and hiv epidemic reality. rethinking hiv exceptionalism: the ethics of opt-out hiv testing in sub-saharan africa the rise and decline of western of western liberalism who test & treat policy and change in art uptake principles of biomedical ethics autonomy and opressed socialisation narrative self-understanding and relational autonomy: comments on mackenzie c. poltera, j, 'narrative integration, fragmented selves, and autonomy'. symposia on gender hiv exceptionalism: development through disease in sierra leone mapping and characterising areas with high levels of hiv transmission in sub-saharan africa: a geospatial analysis of national survey data tocno de?id=g9781 40510 6795_chunk _g9781 40510 67951 7_ss1-271#citat ion hiv/aids is no longer the leading cause of death in africa all sa 63 (cc) at 74 (s. afr moral principlism alone is insufficient, and traditional moral theories remain important for practical ethics reviewed work(s): autonomous agents: from self-control to autonomy by alfred r. mele the politics of person: individual autonomy and social-historical selves autonomy and adaptive preferences the social nature of autonomy from exceptionalism to normalisation: a reappraisal of attitudes and practice around hiv testing civilisation or barbarism: an authetntic anthropology beyond individualism: is there a place for relational autonomy in clinical practice and research the theory and practice of autonomy mapping hiv prevalence in sub-saharan hiv-specific legislation in sub-saharan africa: a comprehensive guman rights analysis communities benefit from door-to-door hiv testing sour grapes: studies in the subversion of rationality autonomy and its limits: what place for the public good a history and theory of informed consent harm to self: the moral limits of criminal law the importance of what we care about ethics of hiv testing in general practice without informed consent: a case series worshiping autonomy the perversion of autonomy: coercion and constraints in a liberal society introduction to philosophy: free will ii afr. comm'n on hum. & peoples' rts the common good. the stanford encyclopedia of philosophy medical law: text, cases and materials the penny has dropped that wellbeing isn't individual but social. the guardian groundwork of metaphysic of morals in nous supplement; 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li, ying; he, su-shuang; wang, lei-lei; wei, yan-yan; yin, lu; chen, jing-xu title: impact of the family environment on the emotional state of medical staff during the covid-19 outbreak: the mediating effect of self-efficacy date: 2020-10-09 journal: front psychol doi: 10.3389/fpsyg.2020.576515 sha: doc_id: 322679 cord_uid: jrsg8pdk during the outbreak of the coronavirus disease 2019 (covid-19), the medical staff was facing severe work pressure, which led to a negative emotional state. the purpose of this study was to explore the relationship between the family environment and the emotional state of the medical staff members during the covid-19 outbreak. due to the importance of self-efficacy in regulating mental health, the mediating role of self-efficacy in the association between family environment and emotional state was also explored. a cross-sectional survey was performed, using an online questionnaire, on 645 medical staff who participated in the epidemic prevention and control tasks during the covid-19 outbreak in beijing. family environment, self-efficacy, anxiety, and depressive symptoms were measured by the family environment scale-chinese version (fes-cv), the general self-efficacy scale (gses), the generalized anxiety disorder scale-7 (gad-7), and the patient health questionnaire-9 (phq-9), respectively. correlation analysis and mediating effect analysis were used to explore the relationships between them. first, a higher prevalence of anxiety (39%) and depressive (33%) symptoms were confirmed among the medical staff. second, the symptoms of anxiety and depression were negatively correlated with the dimensions of cohesion and expressiveness and positively correlated with the dimensions of conflict in the fes-cv scale. third, self-efficacy significantly mediated the association between the family environment and anxiety symptoms (p < 0.001) as well as the family environment and depressive symptoms (p < 0.001). these findings show that a negative family environment was the main predictor of symptoms of anxiety and depression in the medical staff during the covid-19 outbreak. furthermore, we found that self-efficacy played a critical mediating role between the family environment and the symptoms of anxiety and depression. our study also indicates that improvements in the family environment benefit the mental health care of the medical staff, and high self-efficacy enhances this effect. the outbreak of coronavirus disease 2019 continues to attract worldwide attention . to date, covid-19 cases have been confirmed in more than 200 countries around the world, and it has become a public health emergency of international concern. many people who have directly faced this large-scale public crisis, especially the medical staff involved in the prevention and control of this epidemic, showed anxiety symptoms (huang et al., 2020) . they faced a high risk of getting infected at their workplace and the possibility of their family members at home getting infected through them (xiang et al., 2020) . medical staff working in a high-pressure environment suffer from psychological problems, especially anxiety and depression (kang et al., 2015; wang et al., 2020) . although guidelines on the care of the mental health issues in medical staff have been issued in china (kang et al., 2020) , some of the staff refused to receive mental health care . it has been reported that the incidence of anxiety and depression was high among the medical staff during the outbreak of covid-19, with prevalence rates of anxiety and depressive symptoms being 44.6% and 50.4%, respectively (lai et al., 2020) . due to the stigma around mental health problems in china (bai et al., 2004) , many members of the medical staff community were reluctant to accept professional psychological help . however, they preferred to seek help from their family members. some medical staff was far away from their families because of the fear of infection, and they were reluctant to have close contact with them. others were isolated and cannot return home for a long time (raven et al., 2018) . it has shown that family support is very important for medical staff involved in epidemic prevention (mohindra et al., 2020) . however, there has been no research on how family members can help medical professionals suffering from mental health issues and what kind of family environment can be useful in relieving negative emotions in these individuals during an epidemic. the family, which is the basic social unit, may affect the mental health of family members (cheng et al., 2017) . in chinese culture, family relations are highly valued, and family is a very important support system (poulin et al., 2012) . it means that the importance of family is the core feature for most chinese people. previous studies have shown that the family environment can directly affect the emotions in family members, especially the dimension of cohesion (harris and zakowski, 2003; burnett et al., 2017) , expressiveness (luebbe and bell, 2014) , and conflict (yap et al., 2014; yap and jorm, 2015; fosco et al., 2016) . however, whether the family environment has an effect on the mental health of medical staff during the epidemic is still not clear. self-efficacy refers to an individual's judgment about his or her ability to complete a certain task successfully, and it reflects the self-confidence of an individual to cope with various difficulties and setbacks in life (tang et al., 2019) . previous research has shown a positive correlation between the family environment and self-efficacy (mahmoudi, 2012) . individuals with a better family environment were shown to be more likely to have higher levels of self-efficacy (hemati et al., 2020) . for example, individuals can freely communicate with family members, express more about themselves, and have a frequent high contact of intimacy with other family members, which will lead to a high level of selfefficacy (hemati et al., 2020) . studies show that increasing selfefficacy is an essential aspect of the psychological intervention to protect the mental health of individuals (caldwell et al., 2009) . it seems that the higher the self-efficacy in an individual, the better the mental health (sebastian, 2013; jiang et al., 2020) . high self-efficacy can improve an individual's mental health (bandura, 2012 ). however, a low level of self-efficacy harms a person's psychological well-being (cieslak et al., 2008; sachs-ericsson et al., 2011) . importantly, studies have shown that self-efficacy is one of the critical factors that modulate an individual's emotions, especially feelings of anxiety and depression (bandura et al., 1982; kanfer and zeiss, 1983; cybulski et al., 2017; schönfeld et al., 2019) . these studies suggested that higher levels of selfefficacy are associated with lower levels of feelings of anxiety and depression. during the outbreak of sars, medical staff with low self-efficacy often had a higher fear of the epidemic, which was positively correlated with their poor mental health status (ho et al., 2005) . self-efficacy can predict the significant difference in mental health during the epidemic. the lower the self-efficacy, the worse the mental health status (yıldırım and güler, 2020) . it has been found that lower psychological stress among dentists during the covid-19 epidemic is associated with being in a stable relationship and having a higher sense of self-efficacy (shacham et al., 2020) . it suggests that family relationships and self-efficacy during the epidemic may both affect the mental health of medical staff. the partial mediating role of self-efficacy in some psychological trait relationships has been supported by relevant research (haj-yahia et al., 2019) . indeed, it has been found that self-efficacy was a mediator for the association of daily stress and mental health (schönfeld et al., 2019) . however, there has been no study focusing on the relationship between family environment, self-efficacy, and the emotional state of medical professionals during an epidemic. the relationship between family environment, self-efficacy, and depression and anxiety, and whether the influence of family environment on anxiety and depression is regulated by selfefficacy needs to be further studied. therefore, the purpose of this study was to further explore the direct and indirect impact of the family environment on symptoms of anxiety and depression among the medical staff involved in controlling the epidemic. when examining the indirect effects, we took self-efficacy as an intermediary variable. mediating effect analysis was performed to explore the role of self-efficacy in the relationship between family environment and symptoms of anxiety and depression. based on our findings, we provide viable strategies for the family based psychological intervention of the medical staff during an epidemic that will help to improve our psychological crisis intervention system. this research was a cross-sectional study using the convenience sampling method to collect survey results through an online questionnaire. the online survey was conducted in beijing from february 28, 2020 to march 9, 2020. inclusion criteria for the study were as follows: (1) chinese, working in beijing; (2) 18-65 years old; (3) medical staff including doctor or nurse involved in covid-19 epidemic prevention and control; and (3) has read and agreed to the online informed consent. the protocol of this study was approved by the ethics committee of the beijing huilongguan hospital. the family environment scale-chinese version (fes-cv) this scale was based on the family environment scale (fes) developed by moss (moos and moos, 1994) , which was translated into chinese by wang et al. (wang et al., 1999) . the scale has 90 entries in total, including 10 dimensions (cohesion, expressiveness, conflict, independence, achievement orientation, intellectual-cultural orientation, active-recreational orientation, moral-religious emphasis, organization, and control), with nine entries for each dimension. each entry has a true and false option. the higher the score of a particular dimension, the more prominent the characteristics of the family in that aspect. the scores of conflict and control were negatively correlated with the family environment, whereas others positively correlated with the family environment. this scale has been shown to have good structural, content, and external validity when applied to the chinese population (phillips et al., 1998) . in this study, we selected three dimensions of this scale that were closely related to emotions investigated in previous studies: cohesion, expressiveness, and conflict (harris and zakowski, 2003; burnett et al., 2017) . this scale was developed by german psychologist schwarzer (schwarzer, 1995) , which was translated and revised for the chinese version by wang et al. (wang et al., 2001) . the scale comprises of 10 items with four answer options, and the answer options range from 1 (not at all true) to 4 (completely true). higher scores mean higher levels of self-efficacy; a score of 1.0-2.0 means low level, 2.1-3.0 means medium level, and 3.1-4.0 means a high level of self-efficacy. the revised scale has been shown to have excellent reliability and validity in the chinese population (wang et al., 2001) . the cronbach's alpha of this scale is 0.87, the retest reliability is 0.83, and the correlation coefficient between the 10 items and the total scale score is 0.60-0.771. this scale was developed by spitzer et al. (spitzer et al., 2006) . previous research demonstrated that the chinese version of gad-7 has good reliability and validity, and the sensitivity and specificity of this version were 0.86 and 0.95, respectively (huang et al., 2019) . this scale is composed of seven items, and each item has a 0-3 points scale. the total score range is 0-21 points; 0-4 for no anxiety, 5-9 for mild anxiety, 10-14 for moderate anxiety, and more than 15 for severe anxiety. the patient health questionnaire-9 (phq-9) the scale was developed based on the fourth edition of the diagnostic and statistical manual of mental disorders (kroenke et al., 2001) . we used the chinese version of this scale. this scale is composed of nine items, and each item has a 0-3 points scale. the symptom severity is determined by the total score, with 5-9 being mild, 10-14 being moderate, 15-19 being moderately severe, and 20-27 being severe. cronbach's alpha of the phq-9 in the chinese population is 0.86, and the retest reliability is 0.86, which indicates that this test has excellent reliability and validity (wang et al., 2014) . all of the analyses were performed using spss for windows 23.0. we reported means and standard deviations for continuous variables showing normal distribution and frequencies and proportions for categorical variables. the original scores of the dimensions of conflict in fes-cv were not normally distributed and were presented as medians and quartiles. a chisquared test was used to test the relationship between the demographic data of the participants and their anxiety and depressive symptoms. the study participants were grouped based on whether they showed/did not show anxiety or depressive symptoms. the inter-group comparison of the scores of fes-cv and gses was carried out using the independent sample t-test and the independent sample kruskal-wallis test. spearman correlations were calculated to determine the relationships between the scores of the various scales. we categorized the family environment (cohesion, expressiveness, and conflict) as an independent variable, anxiety and depression symptoms as dependent variables, and self-efficacy as an intermediary variable. after controlling for demographic variables, the direct, indirect, and total effects of the family environment on the symptoms of anxiety and depression were examined. the mediation analysis was run on the process macro for spss (preacher and hayes, 2004), using 5,000 bootstrap samples for bias correction and to establish 95% confidence intervals. all of the tests were twotailed, and the significance level was set at p < 0.05. the medical staff involved in this study mainly includes two groups. one is the staff of the hospital involved in treating patients infected with covid-19; the other is the staff at the isolation point, whose main task is nucleic acid testing and medical services for the quarantined personnel. a total of 653 medical staff members completed the online questionnaire, out of which six individuals did not complete the basic information, and two took more than 5 min to answer the questionnaire. thus, 645 medical staff members participated in the study, of which 485 (75%) were women, and 160 (25%) were men, aged 21-65, with an average age of 35.88 ± 8.64. most of the participants were under 40 (75%), had a bachelor's degree (61%), were married (73%), and were living with their families (83%). among these participants, 251 (39%) had anxiety symptoms, and 215 (33%) had depressive symptoms. the symptoms of anxiety and depression were closely related to the gender of the medical staff and whether they lived with their family members or not. the prevalence rate of anxiety and depression symptoms was higher in women (x 2 = 9.25, p = 0.002; x 2 = 4.09, p = 0.043) and in those who did not live with their families (x 2 = 5.38, p = 0.02; x 2 = 4.35, p = 0.037) ( table 1) . we divided the participants into two groups: one group with anxiety symptoms (gad-7 score > 4) and the other group without anxiety symptoms (gad-7 score ≤ 4). we then investigated the significance of the differences in the scores of the two groups for the fes-cv and gses scales. next, the participants were divided into two groups according to whether they had depressive symptoms or not (depressive symptoms: phq-9 score > 4; no depressive symptoms: phq-9 score ≤ 4). like the anxiety symptoms, we investigated the significance of the difference between the scores of fes-cv and gses scales in the two groups. the results, which show the significant differences among groups, are shown in table 2 . next, we used correlation analysis to determine the correlation between the scores of each scale. the results showed that there were statistically significant relationships between the anxiety and depressive symptoms of medical staff, their family environment, and their sense of self-efficacy. anxiety and depressive symptoms showed a significant positive correlation with the dimension of conflict in fes-cv scale (r = 0.29, p < 0.001; r = 0.25, p < 0.001), and a significant negative correlation with the dimension of cohesion (r = −0.31, p < 0.001; r = −0.38, p < 0.001), expressiveness (r = −0.23, p < 0.001; r = −0.30, p < 0.001), and self-efficacy (r = −0.25, p < 0.001). more specifically, individuals with bad family environments and low self-efficacy were more likely to show symptoms of anxiety and depression. besides, selfefficacy positively correlated with the dimension of cohesion and expressiveness and negatively associated with the dimension of conflict (table 3) . after controlling for demographic variables, we examined the mediating effects of self-efficacy (figure 1) . self-efficacy was significantly associated with the symptoms of anxiety and depression. it significantly mediated the association between the family environment and anxiety symptoms (β = −0.12; 95% ci, −0.19 to −0.06; β = −0.10; 95% ci, −0.16 to −0.05; and β = 0.06; 95% ci, 0.02 to 0.11). similarly, it mediated the association between family environment and the depressive symptoms (β = −0.09; 95% ci, −0.16 to −0.03; β = −0.08; 95% ci, −0.14 to −0.03; and β = 0.06; 95% ci, 0.02 to 0.11). when controlling for self-efficacy, the association between the family environment and anxiety symptoms were still significant (β = −0.62, p < 0.001; β = −0.52, p < 0.001; and β = 0.55, p < 0.001) and similarly for family environment and depressive symptoms (β = −0.87, p < 0.001; β = −0.84, p < 0.001; β = 0.55, p < 0.001). thus, self-efficacy partly mediated the relationship between the family environment and the symptoms of anxiety and depression. in the current study, we conducted an online questionnaire survey of some medical staff involved in covid-19 prevention and control in hospitals and isolation sites in beijing. we found that a considerable proportion of medical professionals had anxiety (39%) and depressive symptoms (33%), as noted in previous studies (huang et al., 2020; lai et al., 2020) . moreover, our results showed that the family environment of medical staff and their symptoms of anxiety and depression during the epidemic were closely related to self-efficacy, and self-efficacy partly mediated the relationship between the family environment and the symptoms of anxiety and depression. in this present study, we found that the self-efficacy of male medical staff was significantly higher than that of female medical staff (t = 3.245, p = 0.001). however, the symptoms of anxiety (p < 0.001) and depression (p = 0.002) during covid-19 were significantly lower than that of female medical staff, which was consistent with previous research results. for example, it showed that female medical workers experience higher levels of anxiety, depression, and distress during covid-19 (lai et al., 2020) . it also reported that the self-efficacy of male medical staff is significantly higher than that of female medical staff (tang et al., 2019) . it should also be noted that medical staff who did not live with their families were more likely to have symptoms of anxiety and depression during the epidemic. thus, our study suggests that we should pay more attention to such medical staff and provide them psychological intervention. this observation also indicates that the family plays a certain role in regulating negative emotions. furthermore, our study showed a close relationship between the family environment of the medical staff and their symptoms of anxiety and depression. the medical staff members with low cohesion and expressiveness, as well as high conflict in the family environment, were more likely to show anxiety and depressive symptoms during the epidemic. notably, in this present study, the relationship between the family environment and the symptoms of anxiety and depression reveals that the family environment can, directly and indirectly, affect the emotions of medical staff during an epidemic. the family environment can significantly predict the emergence of anxiety and depressive symptoms directly, which is consistent with previous results. for example, some studies found that there was a correlation between cohesion in the family environment and depression in family members (burnett et al., 2017) ; families with high cohesion, which have high levels of family support and ties, likely reduce depression (park et al., 2018; cano et al., 2020) . in contrast, low family cohesion and conflict between parents increased the risk of depression and anxiety in family members (park et al., 2018; cano et al., 2020) . in families with a high degree of cohesion, individuals can get more psychological help and emotional support within the family (birgisdóttir et al., 2019) , so that the psychological pressure can be appropriately relieved. positive emotional expression within the family can prevent suppression of inner feelings and buffer internal conflicts, especially in the face of stressful events. in contrast, negative emotional expression and low emotional expression within the family are associated with higher anxiety and depression (luebbe and bell, 2014; park et al., 2018) . in a high-conflict family, family members are prone to conflict between each other, leading to anxiety. therefore, the results in this study support the hypothesis that the family environment can influence the emotional state of the family members and that a negative family environment is a psychological risk factor for the rising emotional distress of the medical staff during an epidemic. additionally, the influence of the medical staff 's family environment on their symptoms of anxiety and depression during the covid-19 epidemic is partly through the role of self-efficacy, which means self-efficacy plays a critical role in mediating the effect of family environment on symptoms of anxiety and depression. indeed, previous studies supported that self-efficacy had a protective effect on mental health (bandura, 2012) and played a vital role in the regulation of stress (bandura et al., 2003) . high self-efficacy was related to better psychological adjustment (bandura, 2012) and lower emotional distress (benight and harper, 2002) . individuals with high selfefficacy had positive expectations and beliefs, had successful experiences, generated positive emotions, and were more likely to seek psychological support to modulate their emotions when facing stressful situations (tsang et al., 2012) . a bad family environment can reduce an individual's self-confidence and ability (hemati et al., 2020) . self-efficacy is the embodiment of such confidence and ability (tang et al., 2019) . that is to say, the family environment affects self-efficacy by affecting people's self-confidence and ability, thus affecting individuals' behavioral patterns and emotional responses to stress (tsang et al., 2012) . for example, a medical worker with a good family environment has confidence in the success of the fight against the epidemic and also believes that he is capable of doing his job, which will ease his fear of the epidemic and anxiety about the high-risk work of infection. self-efficacy played a partial mediating role between the family environment and symptoms of anxiety and depression, indicating the existence of other variables between them. future studies should, therefore, include other relevant variables that are likely involved in the relationship between the family environment and negative emotions. this study indicates that adjusting self-efficacy is a meaningful way to regulate the anxiety and depressive symptoms of medical staff during an epidemic. because of the close correlation between the family environment and the symptoms of anxiety and depression of medical staff during an epidemic, we need to pay more attention to psychological assistance for medical staff from the perspective of their family situation. when providing psychological assistance to medical staff during the epidemic, we should not only focus on the medical staff but also care about their family members and family relations. by improving the family environment and increasing the active support of the family, their emotional problems can be effectively alleviated (mohindra et al., 2020) . the focus of the medical staff 's treatment of family relations should be to enhance the intimacy between family members, increase their interaction, encourage them to talk to each other, resolve the family conflicts in time, and create a good family atmosphere. based on the results of this study, we propose the following suggestions for medical staff. first, we suggest that medical staff should have time to communicate with their families and that they should be encouraged to share their feelings with family members and get their support and encouragement. for example, they should be encouraged to record their routines in the hospital and share them with their families . the hospital or isolation point shall provide relevant communication conditions and equipment for this purpose. second, during the epidemic period, the staff of the relevant departments of the hospital should be aware of the difficulties existing in the family of medical staff, and they should guide these staff members and help them solve those problems to avoid family conflicts. third, the family members of medical staff should be aware of the mental health issues of the staff member. family safety plays the most important role in reducing the pressure of medical staff during the epidemic . therefore, the staff members should stay connected with their families through wechat, sms, and other apps to understand their health status, which will help lessen the negative mental state of the medical staff during the covid-19 pandemic outbreak. these suggestions can bring medical staff closer to their families, have more emotional communication, and reduce family conflicts. with the implementation of these measures, the medical staff 's sense of self-efficacy will also be improved. besides, our results suggest that improving self-efficacy will help to alleviate the anxiety and depressive symptoms of medical staff during the covid-19 outbreak. manipulating self-efficacy is an important way to prevent mental health problems when dealing with stress (schönfeld et al., 2019) . previous studies have focused on the effects of self-efficacy on the mental health and work quality of medical staff (amiri et al., 2019; tang et al., 2019) , and it suggested that necessary interventions should be implemented to improve the self-efficacy of medical staff. in the prevention and control of covid-19, medical staff is faced with two main difficulties. on the one hand, medical staff has heavy work tasks, great pressure, high risk of infection, and lack of support (spoorthy et al., 2020) . on the other hand, most of the medical staff are required to be isolated in hospitals or isolation points. their families will face more prominent problems (mohindra et al., 2020) . some positive motivation factors can boost morale and improve the self-efficacy of medical staff, such as family and social support, positive example, recognition, and appreciation from others, successful experience, self-identity (spoorthy et al., 2020) . positive feedback and encouragement from others could also effectively improve self-efficacy (bandura, 1997; zinken et al., 2008; brown et al., 2012) . the pre-job training, encouragement from colleagues and family, affirmation from patients and society, and sufficient material support were all helpful ways to improve the self-efficacy of medical staff during the covid-19 outbreak. medical staff in a good family environment can get better family support. the support reduces the sense of uneasiness caused by isolation, and improve self-efficacy, increase work confidence, improve work efficiency and quality, and reduce the negative emotions caused by epidemic infection. it has been reported that the mental health status of chinese medical staff is poor (zhou et al., 2018) , and they are exposed to immense workplace pressure and face complex doctor-patient relationships. the reason lies in the contradictions in the current medical system reform in china, such as the uneven distribution of medical resources (lu et al., 2019) , the disequilibrium between health care needs and medical development (zhou et al., 2018) , and the imperfection of the medical system (ta et al., 2020) . during an epidemic period, protecting the mental health of the medical staff would benefit their health as well as the control of the epidemic worldwide (kang et al., 2020) . the national health commission of china has published a national guideline of psychological crisis intervention for covid-19, which is guided for the protection of the mental health of the medical staff (kang et al., 2020) . however, the family environment is particularly important to the mental health of the medical staff, and self-efficacy plays an important role in regulating the relationship between them. appropriate guidelines should be issued nationally to improve the family environment of the medical staff and for the improvement of their selfefficacy. there are some limitations to the current study that need to be addressed. first, there are limitations to the method of sampling. sampling bias may have occurred by using a convenient sampling method. second, we have a small sample size, and all participants are from beijing, so the research participants in this study may not be sufficiently representative of the population we are interested in studying, which may limit the conclusion of research results. third, online questionnaire surveys cannot observe the participants' answering process, there is the possibility of random answer and perfunctory answer, cannot guarantee the complete authenticity of data. fourth, we did not measure other potential confounding variables that may exist between the family environment and the emotional state of medical staff during the covid-19 outbreak. finally, the researchers are all medical staff, and the design of the survey may be more based on clinical observation. in the future, the research design can be combined with clinical observation and the existing theoretical framework. in the current study, we found that the anxiety and depressive symptoms of medical staff during the covid-19 outbreak was closely related to their family environment, and their self-efficacy regulated the relationship between them. this study provides a new direction for the psychological intervention in medical staff during the epidemic that mainly focuses on improving their family environment and their self-efficacy. the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher. nh contributed to the manuscript writing. j-xc, yl, and s-sh contributed to the conception and 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langbeheim, elon; perl, david; yerushalmi, edit title: science teachers’ attitudes towards computational modeling in the context of an inquiry-based learning module date: 2020-08-25 journal: j sci educ technol doi: 10.1007/s10956-020-09855-3 sha: doc_id: 352431 cord_uid: yu7kxnab this study focuses on science teachers’ first encounter with computational modeling in professional development workshops. it examines the factors shaping the teachers’ self-efficacy and attitudes towards integrating computational modeling within inquiry-based learning modules for 9th grade physics. the learning modules introduce phenomena, the analysis of measurement data, and offer a method for coordinating the experimental findings with a theory-based computational model. teachers’ attitudes and self-efficacy were studied using survey questions and workshop activity transcripts. as expected, prior experience in physics teaching was related to teachers’ self-efficacy in teaching physics in 9th grade. also, teachers’ prior experience with programming was strongly related to their self-efficacy regarding the programming component of model construction. surprisingly, the short interaction with computational modeling increased the group’s self-efficacy, and the average rating of understanding and enjoyment was similar among teachers with and without prior programming experience. qualitative data provides additional insights into teachers’ predispositions towards the integration of computational modeling into the physics teaching. electronic supplementary material: the online version of this article (10.1007/s10956-020-09855-3) contains supplementary material, which is available to authorized users. al harrison. "maybe we've been thinking about this all wrong" paul stafford, "how's that"? al -"maybe it's not new math at all" katherine johnson -"it could be old math, something that looks at the problem numerically and not theoreti-cally… math is always dependable" al -"for you it is." (leaving the room) katherine -"euler's method!" paul -"euler's method? but that's ancient!" katherine -"it is ancient, but it works…" (scene from theodore melfi's film "hidden figures," 2016). this excerpt describes the breakthrough of the nasa team working on the calculation of the re-entry coordinates for john glenn's first orbital flight outside the atmosphere. when faced a problem that cannot be solved analytically, katherine johnson, the woman who worked as the team "calculator," suggested to use the euler method-a step-by-step calculation for solving the differential equations of motion (develaki 2019) . today, the euler method is implemented in computer models that are investigated in introductory physics courses (e.g., chabay and sherwood 2008) and allows educators to expand the scope of problems that students can tackle. developing and using computational models reflects an important goal for k-12 science education, within a range of scientific practices such as designing and employing experimental investigations, analyzing measurement data and communicating them (nrc 2012) . indeed, there is growing evidence for doing classroom inquiry that entails a dual focus on experimental measurement and computational modeling in primary and secondary schools (e.g., farris et al. 2019; fuhrmann et al. 2018) . the extent to which teachers adopt inquiry-based science teaching practices may be related to their views of inquiry learning (lotter et al. 2007; osborne 2014; blanchard et al. 2009 ), their subject matter knowledge (tseng et al. 2013) and their teaching self-efficacy (lakshmanan et al. 2011 ). however, research on teachers' attitudes towards integration of computational models in the context of experimental investigations is scarce (gerard et al. 2011) , and thus, teachers' implementation of instruction that involves both experimental classroom inquiry and construction of computational models, remains an open field of research. in this paper, we describe science teachers' engagement with inquiry-based curricular modules for 9th grade physics that introduce computational models. the modules include a structured, inquiry-based experimental component, and a theoretical component in which computational models are used to verify the experimental observations. drawing on studies that address teachers' attitudes and self-efficacy as indicators for implementation of inquiry teaching, we ask how do teachers' prior experiences in teaching physics influence their self-efficacy and attitudes towards inquiry-based learning practices? specifically, in relation to computational modeling, we ask how does teachers' prior involvement with programming influence their self-efficacy in, and experience of computational modeling? coordinating theory and experimental evidence: a model-based perspective a scientific investigation integrates two endeavors: the formation or revision of predictive theoretical constructs and the design of experiments that produce reliable observations or measurements (klahr and dunbar 1988) . in studying the development of scientific practices among students, researchers can focus on practices of experimental design such as the selection and control of variables (chen and klahr 1999) or the evaluation of measured data (allie et al. 1998; kanari and millar 2004) , or they can study how students use and conceptualize theoretical ideas. in practice, the two activities are difficult to separate. specifically, unsubstantiated hypotheses, or "implicit theories" (kuhn 2011 ) have a strong influence on students' planning and interpretation of experiments. conversely, flawed experimental design, or misinterpretations of measurements can shape theoretical misconceptions. judging experimental results as implausible in light of learners' "naïve" theories is a crucial aspect of the theoryexperiment interaction (kuhn 2011) . in many introductory college and high school courses, the interaction between theory and experiment plays out in structured labs designed to "prove" or concretize theoretical statements. although the purpose of these labs is to substantiate the theory students learn in lecture courses, studies show that they do no contribute to students' content knowledge, as measured by test performance (holmes and wieman 2018) . moreover, students' perceptions of their own expertise in conducting experiments tend to decline during such structured laboratory courses (wilcox and lewandowski 2018) . an alternative is the inquiry or design lab that entails discovery experiments that extend the theoretical knowledge students acquired in prior learning. for example, in the investigative science learning environment (isle) curriculum (etkina et al. 2006a) , students design experiments to develop and then test model-based explanations of observed phenomena. this approach brings the design of experiments and the analysis of measurement data to the fore, and often challenges students' prior knowledge. to do so, an extended amount of time is allocated to judging the reliability of measurement data. educational research shows that in these transformed labs, there is no decline in students' perceptions of their expertise in conducting experiments as in the structured lab (wilcox and lewandowski 2018) . a specific case of coordinating theory and experiments is the construction and evaluation of models. models are simplified, and often abstracted quantitative representations of the system under investigation, constructed to describe, explain or predict the system's behavior (etkina et al. 2006b ). in introductory physics courses, models are usually instantiations of general, theoretical principles such as newton's laws, in generic systems such as orbital motion under the influence of a centripetal force (halloun and hestenes 1987) . recently, researchers who design upper-level laboratories, suggested a new modeling framework, in which model construction, evaluation and revision is utilized for two inter-connected modeling cycles: the measurement model cycle and the theoretical model cycle (zwickl et al. 2015; dounas-frazer and lewandowski 2018) . this framework provides two possible reactions to a misalignment of theory-based model and measurements: revising the measurement model-the instruments used or the interpretation of the measurement data, or, revising the theoretical model. while this framework has been suggested for upper-level undergraduate labs that often involve sophisticated measurement equipment, it is a useful construct for guiding scientific investigations at various levels. it suggests designing investigations with explicit awareness to both the judgment of measurement data, and to the limitations of the theory-based, physical system models. the measurement and/or the theoretical models can be revised to achieve better alignment of theory and the behavior of the actual physical system. while most examples of theoretical system models are mathematical/analytical (e.g., dounas-frazer and lewandowski 2018), these models can be also realized using computer simulations, as we will show bellow. jong et al. 2013) . in this approach, students manipulate parameters of the simulated system to learn about its mechanism. the simulations are introduced as substitutes of the real system and the interaction with them resembles a structured laboratory experiment. for example, students investigate a simulation of collisions and compare the velocities before and after the collision to deduce the law of conservation of momentum (de jong et al. 1999) . a different educational approach is to engage students in constructing the computational model (vanlehn 2013; wagh and wilensky 2018) . engaging in model construction requires learning environments that allow students to add or change model features. the students need to plan how to add or change certain aspects of the model, and then run the computational model and compare the outcome vis-à-vis other realizations of the theory or experimental results. for example, in a computational model of a falling paratrooper, students decide whether the magnitude of the drag force depends on the velocity or not. they then examine whether their definition of the drag force yields a velocity pattern that reaches a relatively low terminal velocity as expected (develaki 2017) . constructing computational models and especially accessing their code has been explored in secondary school physics (aiken et al. 2013; sherin et al. 1993; langbeheim et al. 2019; hutchins et al. 2020) , and in a few introductory college texts (redish and wilson 1993; chabay and sherwood 2008; orban et al. 2018) . however, there are only few examples of using simulations side by side with experiments. for example, farris et al. (2019) investigated how 4th graders learn the concepts of speed and acceleration by measuring the motion of toy cars and building models of motion in a computational environment. despite its basic level of content, this study shows that even young students are able to think about variations in measurement, and relate real-world observations to computational models. similarly, in fuhrmann et al. (2018) students studied the osmosis of sugar water through an egg membrane experimentally and then explored a computer, particle-based model that mimics the experimental results. they found that both exploring a ready-made model and designing a model in this approach foster the development of conceptual knowledge about the topic. however, only actively designing the model results in developing nuanced understanding of the role of models in scientific investigations. this finding emphasizes the epistemic importance of constructing models, compared to just exploring them. engaging students in building computational models reflects the actual practice of scientists (develaki 2017; winsberg 2010 ) and contributes to the development of creativity and computational thinking (hutchins et al. 2020; popat and starkey 2019) . however, letting students construct models, and especially when construction involves the understanding and manipulation of computer code, is a much greater leap for educators. in order to guide students in understanding and modifying code, teachers need to become proficient in programming themselves and to produce new learning materials for their science and mathematics classrooms. this requires teachers and students to transition from being users of computer programs to being builders of programs, which can be viewed as a substantial change in computing culture (ben-david kolikant and ben-ari 2008) or an educational paradigm shift (disessa 2001). implementing inquiry-based teaching that involves designing experiments, interpreting measurement data, and constructing models is challenging. in this study, we consider two main factors that determine the extent to which teachers implement such teaching in their classrooms: (1) teachers' self-efficacy in teaching the subject matter (e.g., lakshmanan et al. 2011); (2) teachers' attitudes regarding inquiry-based learning and their beliefs in its effectiveness (blanchard et al. 2009 ). self-efficacy is a set of beliefs regarding one's capabilities to perform well in a certain field (bandura 1997) . these beliefs are one of the main driving forces that motivate people to put effort and pursue challenging tasks. self-efficacy beliefs are dynamic, especially during learning of new skills, or beginnings of new professional endeavors. in preliminary acquisition of an expertise, there are several factors influencing self-efficacy, such as observing others demonstrating successful performances, and most importantly, one's own mastery experiences. mastery experiences are successful performances of tasks, such as conducting an effective lesson or lesson sequence. teaching self-efficacy determines teachers' beliefs about their competence and performance in teaching (tschannen-moran et al. 1998 ). teachers' years of experience in teaching are significantly correlated with their teaching self-efficacy (tschannen-moran and hoy 2007) but not with their tendency to implement inquiry-based teaching (marshall et al. 2009 ). although physics is considered a challenging topic, studies of self-efficacy of teaching physics are very rare (e.g., tanel 2013) . the second factor influencing implementation of inquiry-based teaching is teachers' beliefs regarding the importance and fruitfulness of this type of teaching. teachers' who were less inclined to believe that inquirybased teaching methods lead to effective student learning were less likely to implement them in their lessons (lakshmanan et al. 2011) . similarly, teachers who had meaningful views of the pedagogical approaches to inquiry, grounded in learning theories, were more likely to adopt inquiry-based learning practices in their classrooms (blanchard et al. 2009 ). reformed teaching pedagogies and curricula are usually introduced in professional development (pd) workshops, so that successful implementations can be related to the teachers' backgrounds and/or to the pd process. the structure, duration, and content of pds is an important factor influencing the implementation of reformed instruction and curricular innovations. a survey study showed that pds that focus on content knowledge and provide opportunities for active learning have the strongest positive effect on teachers' self-reported increase in knowledge and skills (garet el at. 2001) . moreover, pds that include mastery experiences have the strongest effect on teachers' self-efficacy (tschannen-moran and mcmaster 2009) and consequently on classroom implementation (penuel et al. 2007 ). there are only few examples of teacher training programs that include computer programming (e.g., repenning et al. 2020) . such courses are necessary for boosting their selfefficacy in computational modeling and knowledge of computational thinking (papadakis and kalogiannakis 2019). a growing number of studies indicate that elementary and secondary school students are able to construct computational models and to modify their code in the context of physics (e.g., aiken et al. 2013; langbeheim et al. 2019; farris et al. 2019 ), but less is known about the views of in-service science teachers regarding adopting computational modeling that involves manipulation of computer code. therefore, the goal of this study is to examine science teachers' attitudes towards introducing computational model construction in the context of inquiry-based learning in physics. our main research questions are: 1. how do teachers' prior experiences in teaching physics influence their self-efficacy and attitudes towards inquirybased learning practices in a pd workshop? 2. how does teachers' prior involvement with programming influence their self-efficacy in, and experience of computational modeling that involves coding in a pd workshop? we investigated these questions in the context of workshops that introduced two curricular modules for 9th grade physics: the focus of the first is the oscillations of a springmass system, and the focus of the second is free-fall with airdrag. each module begins with experimental investigations of motion patterns, and concludes with a theoretical section that compares the experimental measurements to the output of computational models. the experimental section of both modules comprised six 90min lessons that are summarized in table 1 . the lessons are based on the following design guidelines: a) capturing student attention-the main purpose of initial lessons is to raise attention to aspects of the phenomenon through problematization (reiser 2004; phillips et al. 2017 ). in the first module, the theoretical exploration focuses on the "peculiar" lack of covariance of the period of the oscillating spring system and its amplitude. in the second, it focuses on the apparent discrepancy between the aristotelian view (that mass influences the falling rate of objects) and the galilean view (that it does not). b) scaffolding measurement and data analysis practices-the measurement and data analysis methods are introduced in a guided manner in the initial lessons. in subsequent lessons, the teacher removes some of the direct instructions: first in asking students to plan and justify an experimental design to answer a common research question (e.g., how does the falling rate of paper cups change when increasing its mass?) and then in planning and justifying an experimental design to study a question that students generate by themselves (see table 1 for examples) c) raising student accountability-students build an evaluation rubric for experimental investigations based on fabricated student reports, in order to develop awareness for reporting standards. then, they share their evaluation criteria to produce a unified rubric. finally, they use the consensus evaluation rubric to provide feedback on the presentations of their peers. after completing the experimental section, and sharing their inquiry projects using posters or presentations, the students proceed to study a theoretical model of the phenomenon. the theoretical section includes a qualitative, conceptual section and the quantitative computational section. the qualitative, conceptual section comprises two lessons in which students construct a paper and pencil theoretical model that explains the phenomenon that they investigated experimentally. for example, in the oscillating spring-mass unit, students analyze the trace of the oscillating mass, using motion patterns produced by the tracker video analysis software (brown and cox 2009 ). their analysis leads to the discovery that the maximal speed of the mass corresponds to the amplitude, or the distance covered by the mass during one period of oscillation. this finding is used to hypothesize qualitatively that the length of the motion path and the average speed of the mass cancel each other out, and therefore, their ratio-the period of one oscillation-is constant. the purpose of the final unit in the module is to introduce a quantitative approach for comparing the measurements and the theory-based model. the analytical equations of motion of both processes we discussed-harmonic oscillations and falling with a drag force-are nonlinear and involve mathematics beyond that of 9th grade. in order to overcome the mathematical complexity, we introduced the theoretical model using a computer program that calculates the trajectory using the euler method (cromer 1981; develaki 2019) . the computational models of motion with air drag and of the oscillating spring-mass systems were realized using trinket.ioa free, online tool for building coding activities and courses. we chose this platform, since it runs vpython-a 3d graphical package for python (scherer et al. 2000) . python was chosen since it replaced introductory level programming languages that were used in the past such as pascal, basic, and fortran. figure 1 illustrates the trinket interface that has the code on the left side and the graphic output on the right. the unit introduced all the necessary programming ideas so that students (and teachers in the pd workshop) were not expected to have prior experience with vpython. the supplementary material provides detailed information on the introduction of the computational model. the euler method presents the theoretically predicted motion pattern using three linear equations, calculated repeatedly every time step. the first equation calculates the net force according to the current location or velocity of the object; the second calculates the new velocity of the object, based on newton's 2nd law; and the third updates the location of the object based on the new velocity. for example, the implementation of these three equations for the falling with air drag problem is shown in lines 14-16 of the code shown in fig. 1 . in addition to using relatively simple linear equations, this approach promotes the analysis of the dynamics of specific moments during objects' motion patterns, thereby facilitating the comprehension of the process as a whole (sherin et al. 1993; sherin 2001) . the two modules were introduced in two summer pd workshops that span four full days and a total of 30 hours of contact. the workshops included an overview of the principles of inquiry-based learning, engaging in measurement cycles and in coordinating the experimental results with the computational model. the workshops were advertised as introducing inquiry for 9th grade physics, and did not as present themselves as focusing on computational modeling. the first 2 days of the pd focused on experimental investigations, and the last 2 days focused on the related theory and computational modeling. teachers worked in small groups and shared their experiences in discussions with the rest of the participants and the workshop instructors. of 49 participating teachers, 41 completed all of the activities. within this group, 26 teachers are considered "experienced teachers"-teachers who taught physics at the 9th grade level for at least 3 years, or at the high school level for at least 1 year (high-school teachers usually come with a bachelor in physics, and teach more physics in 1 year than 9th grade science teachers do in 3 years). fifteen teachers were considered "novice teachers," if they taught physics in 9th grade for less than 3 years. three years is a common cutoff for differentiating experienced and novice teachers in educational research (e.g., tschannen-moran and hoy 2007). this does the mass of an object influence its falling rate? the dispute between aristotle and galileo 2. initial problematization of measurement how to measure the period of oscillation of a mass on a spring when the motion fades? why does the mass of paper cups influence their rate of falling whereas the mass of clay balls does not? 3. joint investigations: drawing conclusions despite measurement uncertainties students systematically investigate the influence of amplitude on the period of oscillation of the mass-spring system students systematically investigate the differences between falling rates of paper cups, while increasing their mass, and discover that the differences decrease with mass 4. developing an evaluation rubric students were given an empty evaluation rubric and three fictitious student reports. they suggested categories, and differentiated between performances on each category. students chose a research question related to the period of oscillation of a spring mass system (e.g., what happens when increasing the suspended mass), suggested hypotheses and built an experimental setup to test their hypotheses. students chose a research question related to falling motion (e.g., how does the diameter of a balloon influence its falling rate), suggested hypotheses and built an experimental setup to test their hypotheses 6. peer evaluation students present their posters/presentations to their peers, and peers provide written or oral feedback based on the evaluation rubrics. group consisted of new teachers, and a few experienced teachers in other fields such as math, who were new to teaching physics topics. the first research question asked how do teachers' prior experiences in teaching physics influence their self-efficacy and attitudes towards inquiry-based learning practices in a pd workshop. to examine this question, we used the following data sources: 1a. physics teaching self-efficacy survey-before the workshop, we administered a self-efficacy survey with six likert-scale items of the same format: "i am confident in teaching quantitative problem solving/ introducing computational models/ textbook experiments, in 9 th grade physics" on a scale of 1 to 5 (5 = strongly agree, 4 = agree, etc.) and a background survey indicating years of experience in teaching physics and experience in computational modeling. the internal consistency of the selfefficacy scale was high-cronbach α = 0.85. 1b. workshop appreciation survey-at the end of the workshop, we administered a feedback survey with six five-point likert-scale items such as "the workshop contributed to my ability to explain fundamental concepts such as newton's 1st law/ textbook experiments etc." (strongly agree, agree, etc.) and open-ended items asking to state aspects of the workshop that they found significant and aspects that were lacking. 1c. attitudes towards physics lab goals-we administered a 15-item survey to evaluate teachers' beliefs about the goals their students should achieve in the physics lab. some of the items were adapted from the e-class -colorado learning attitudes science survey for experimental physics, (wilcox and lewandowski 2018) . the e-class includes items such as "the primary purpose of doing physics experiments is to confirm previously known results (strongly agree, agree etc.)". our adapted version was: "rate the following statements representing goals for students to achieve in the physics lab: to confirm the theory discussed in class." this statement reflects a common goal for the structured lab, while statements such as "to acquire tools for evaluating the work of peers" represents a goal of an inquiry-based lab. the survey utilized a 4-level likert scale. we used exploratory factor analysis to aggregate fifteen statements into two categories: (a) goals of inquiry-based laboratory practices, (b) goals of structured laboratory practices. the full list of items, the corresponding categories and internal consistency scores are shown in table 2. 2. in order to investigate the 2nd research question regarding the influence of teachers' prior involvement with programming on their self-efficacy in, and experience of computational modeling that involves coding in a pd workshop, we used the following data sources: a. programming self-efficacy-before and after the computational modeling activity we administered a self-efficacy survey with three five-point likert-scale items such as: "i think i can understand / write and modify computer code" (strongly agree, agree ,etc.). thirty-eight teachers responded to the pre and post self-efficacy items related specifically to the computational modeling activity. the internal consistency of the self-efficacy scale was substantial-cronbach α = 0.76, but the distribution of the ratings in the posttest was not normally distributed (shapiro-wilk w = 0.94, p = 0.03) fig. 1 vpython code of the computational model (left), and graphical interface (right). the code includes two definitions of graphical objects: the "box" (line 9) which imports the motion diagram of the real object (marked in red dots) and a green sphere (defined as "s" in line 10) which moves according to a computational model. the green trace of the sphere is compared to the red pattern of dots that was produced from a video of a falling paper clip using the tracker software b. programming activity appreciation-three statements addressed specifically the coding activity "the coding activity was interesting," "the coding activity improved my understanding of the physics of the spring-mass system / free-fall with drag," "i understood everything i did in the coding activity" (strongly agree, agree, etc.). the internal consistency of the activity appreciation scale was substantial-cronbach α = 0.74. the full survey can be found in the online supplement. in addition, we used transcripts from the activity itself to corroborate our survey findings. the self-efficacy related to teaching physics in 9th grade was relatively high before the workshop with an average rating of 3.91 out of 5. the average ratings of the novice teachers with less than 3 years of teaching was 3.566, and the experienced teachers average rating was 4.10. this difference is significant (t = − 2.56, p = 0.017). the characterization of teachers' perceptions of the contribution of the workshop was based on two forms of data: likertscale ratings and open-ended questions. the average ratings were calculated and analyzed according on the teachers' experience as shown in table 3 . both groups rated the contribution of computational modeling (item 6) and designing the experimental setup (item 3) higher than the rest of the topics. the contributions to two common aspects of teaching-conducting standard textbook experiments (item 2) and clarifying fundamental physics concepts (item 5)-were rated higher by the novice teachers, and these differences were marginally significant. in the other categories, the differences between the experienced and novice teachers were very small. also, an index measure, combining all of the items, reveals no significant difference among groups (t = − 0.146, p = 0.88) and between workshops (t = − 1.21, p = 0.23). the responses to the open question, corroborate these findings. for example, in their suggestions for two or more aspects of the workshop that contributed to their teaching, vera, an experienced teacher wrote: the inquiry-module for ninth grade, structured and original, will greatly facilitate my work next year. i learned to use excel for analyzing an experimental graph and fitting it to an equation. the main contributing aspects were the parallel investigations, the discussions about classroom inquiry, its meaning and its implementation. also, the acquaintance with the step-by-step method using the software (although i'm not sure i would implement it in class). table 2 the grouping of the items regarding the goals of the physics lab "rate the importance of the following statements representing goals for students to achieve in the physics lab" cronbach's α (pretest) cronbach's α (posttest) (a) inquiry-based laboratory goals "an active, hands-on acquaintance with physical systems" 0.82 0.79 "acquire tools for evaluating the work of peers" "acquire tools to improve group work" "to present and report findings to peers (using presentations/posters)" "to identify sources of measurement error" "to make inferences from experimental findings" "to learn to improve the experimental setup to increase measurement accuracy" "to design an experimental setup to investigate the quantitative relation between two variables" (b) structured laboratory goals "to illustrate and concretize the theory discussed in class" 0.64 0.81 "to learn to write reports of experimental findings" "to confirm the theory discussed in class" "to learn methods for analyzing and presenting data" "to understand the role of experiments in building theories" "to work with the safety regulations related to equipment and materials in the lab" "to search and find information sources" (relevant to the experiment) both teachers mentioned the structured inquiry sequence as a major contribution to their teaching. in relation to the computational tools, vera mentioned excel which was used to analyze the experimental data, and ana mentioned step-by-step computational modeling. overall, teachers mentioned five main components of the pd: the two most common topics, both mentioned by 54% of the teachers, were the structured inquiry sequence and/or the computational modeling activity. in addition, 41% mentioned the measurement error analysis and/or the active learning format of the workshop. finally, 24% of the teachers mentioned the contribution of the workshop to their understanding of fundamental physics concepts. the differences in attitudes towards laboratory experiments before and after the pd were relatively minor as shown in table 4 . the teachers' rating of the importance of lab purposes associated with traditional structured lab (category b.) decreased during the workshop, and goals related to inquiry practices have slightly increased. however, a closer examination shows that these differences were not the same across groups. the ratings of inquiry lab goals among novice teachers increased, whereas the experienced teachers' ratings slightly decreased. this difference is marginally significant (p < 0.1). the average rating of programming self-efficacy before the activity was 3.11 (sd = 1.01), and at the end of the workshop, it increased to 3.65 (sd = 0.93). a wilcoxon signed rank test shows that the difference between pretest and posttest is significant (w = 930, p = 0.030). fifteen teachers stated that they had prior knowledge in programming, and 23 responded they did not. we found significant differences in self-efficacy both pre and post the activity, between teachers that declared to have prior knowledge in programming and teachers who did not. teachers with prior programming knowledge rated their self-efficacy significantly higher than teachers without such knowledge, both in the pretest (t = − 3.49, p = 0.0013) and in the posttest (w = 80, p = 0.0055). a wilcoxon test shows that appreciation of the coding activity was similar among teachers with (m = 3.93, sd = 0.55) and without (m = 3.46, sd = 1.08) prior experience in programming (p = 0.239). we note that the standard deviation among teachers with no background in programming was larger than among teachers with programming background. this variance is also evident in the boxplot in fig. 2 (left) . a scatter plot of the activity appreciation ratings vs. the self-efficacy of the teachers is shown in fig. 2 (right) . the red circle shows seven teachers with no prior programming experience and low selfefficacy prior to the activity, which gave high rating to the programming activity. in order to examine the variation in the appreciation of the activity among the teachers without prior programming knowledge, we present excerpts from the activity of two teachers: vera, an experienced physics teacher with over 20 years of teaching, and ana, a novice teacher in her first year of teaching. the two teachers were trying to modify the code in the first part of the computational modeling activity (see online supplement): v: if i want to do this, and place it (the graphical object) in a different initial location then… (trying to modify the code) it doesn't work. why didn't it change anything? oh! what have i done? i erased everything! a: maybe press here? v: no, here. but i didn't save, so now what? start over? a: no, do this (points to the "remix" button) to go back to the original. that is odd, it leaves the shapes, but not the code… v: i hate this! i really, really, hate this entire thing. it's annoying. a: i really like (unclear) v: i like excel a: excel is really awesome, v: it is helpful. it is the most convenient tool! vera is frustrated with the computational modeling activity because of the technical problem that erased the changes in her code. this incident results in her saying that she "really, really hates this entire thing." ana, on the other hand, responded with more patience, and even said she likes the modeling activity. they both also agreed that excel is a useful tool. vera also rated her appreciation of the activity lower than ana at the end of the workshop. the following excerpt indicates that while vera is an experienced physics teaching and very confident with her physics teaching, she is insecure when it comes to computational modeling: instructor: how is it going? v: it's annoying…i cannot compete with them (the students) in this (points to the screen), they will defeat me. our students learn python programming in 8 th grade... inst: but they cannot defeat you in physics… v: listen, when i teach them excel, i am the (authority)… vera is afraid that her authority would be undermined by the students who know more programming than she does. again, she mentions excel as a software that she is confident in using. ana, on the other hand, is a new teacher and does not feel the tension between her confidence in teaching physics, and introducing this new task. it also reminds her something she seemed to like as a child. v: let's move one a: do you remember basic? (programming language), "if-then, goto" (functions in basic) v: i've heard of it, but never used it a: when i was 12 years old i was in an afterschool program (that introduced basic) the excerpt shows that ana had some experience in programming as a child, whereas vera had none. this minor background detail might also explain their different approaches to computational modeling and indicate the importance of early exposure to computer programming. this study addressed two research questions-the first asked how prior experience in teaching physics influenced teaching self-efficacy and attitudes towards inquiry-based laboratory practices. the findings indicate that prior experience in teaching is strongly related to teachers' self-efficacy of teaching physics. this finding corroborates bandura's theory that self-efficacy emanates from mastery experiences of performance (bandura 1997) . the significantly higher self-efficacy fig. 2 appreciation of the activity was similar and positive among both teachers with prior programming experience, and those without (left). scatter plot of the appreciation and the selfefficacy of the teachers before the activity (right) in teaching physics of the experienced teachers is also in line with prior research on the effect of experience on teaching selfefficacy (tschannen-moran and hoy 2007). while experience was related to self-efficacy, the overall appreciation of the learning modules was positive among both experienced and novice teachers. this is true for the appreciation of the experimental and computational aspects of the modules, and specifically in relation to the computational modeling activity. table 3 shows that for the two main aspects of the workshop-computational modeling and conducting structured inquiry (items 3 and 6)both groups responded similarly, and positively. the workshops' purpose was to introduce a novel approach for coordinating experimental measurements and theoretical, computational modeling. this approach differs from traditional structured labs that aim at illustrating or reinforcing theoretical concepts. teachers' decrease in ratings of traditional goals, and the increase in ratings of inquiry practices related to the coordination of experimental results and theory, indicate that the workshop had some influence on the attitudes towards the main goals of the lab. teachers' ratings of inquiry lab practices such as designing an experimental setup indicate difference between experienced and novice teachers that are marginally significant. the differences may be related to prior acquaintance with inquiry practices: the mastery experience in the workshop might have boosted the novice teachers' belief in the importance of these practices, but not those of the experienced teachers who were already confident. this is similar to the differences in lab ratings of first-year undergraduates and students in more advanced years: first year students had lower initial ratings than students in their second year or beyond (wilcox and lewandowski 2018) . this difference probably reflects a process of self-selection-students or teachers who persist in their degree or teaching-are more likely to have positive attitudes towards the importance of the practices that they acquired (wilcox and lewandowski 2018) . the second research question addressed the relation between prior involvement with programming, self-efficacy, and attitudes towards the computational modeling activity. we found that the self-efficacy related to programming of most teachers has increased during the workshop, although teachers with no programming experience were still less efficacious than the teachers with programming experience at the end of the workshop. in addition, the appreciation of the computational modeling activity was similar among teachers with or without programming experience but the groups differed in the variation of their ratings, which was larger among the novice teachers as indicated in the error bars of the boxplot in fig. 2 . the transcript of the computational activity offers an explanation for this variation-it illustrates how two teachers without prior computer programming knowledge reacted differently to the computational activity. the conversation between the two teachers hints that the difference in appreciation may be rooted in different dispositions towards the adaptation of new technologies: vera expressed resentment towards the computational modeling activity and contrasted it with her satisfaction with excel-a user-friendly interface for data visualization that was also used in the workshop. conversely, ana mentioned that the programming activity reminds her a positive experience from the past. vera's reaction reflects the difficulty in switching from the "culture" of computer users of programs such as excel to the "culture" of computer programmers that requires planning and debugging (kolikant and ben-ari 2008) . one way to overcome such barriers is by introducing programming to children at a young age to prevent the perpetuation of the culture focusing on merely using readymade computer artifacts, to a culture views the computer as tool for developing new artifacts (disessa 2001). vera's comments might also indicate that she does not see the value of the computational model. it might be that she could benefit from a framing activity that would explicate the opportunities afforded by the computational modeling activity, and its difference from the excel. for example, the computational model uses symbols for the variables of force "f" and velocity "v" and allows to perform calculations with them (see lines 14-15 in fig. 1 ) this type of representation is not possible in excel, nor is it possible to simulate motion in a dynamic manner. at the beginning of this paper, we referenced the "hidden figures" movie scene to introduce the computational euler method as a legitimate, and sometimes even necessary, substitute for analytical/mathematical modeling. we believe that since computational modeling plays a central and indispensable role in scientific inquiry, this practice needs to be represented in school science, and the only way to do this is by investing in teacher pd. in this study, we examined science teachers' reactions towards a pd workshop that introduced inquiry-based modules with a computational modeling component. we found that the workshop contributed to both experienced and novice teachers. specifically, we found that most teachers' attitudes towards the computational modeling were positive, and their self-efficacy beliefs regarding computational modeling increased. the main limitation of our study is that it does not describe the actual implementation of the modules by the teachers in their classrooms. this would be a subject for an additional study. nevertheless, we note that despite the positive reactions at the end of the workshop, only 25% of the teachers implemented the modules in their classrooms in the subsequent year. some of the teachers were unable to implement the modules because they did not teach 9th grade physics the following year. others did not implement the module, since it required substantial amount of classroom time that they preferred to dedicate to topics mandated by the standard 9th grade curriculum. similarly, farris et al. (2019) wrote that "evident in the teacher's instructional approach was the tension between supporting students' exploration (of the computational model) and the curricular need for the production of canonically correct representations… that are mandated by the curriculum and that they would need in standardized tests." we conclude that in order to encourage more teachers to implement such time consuming, challenging learning modules, they should be included national curricula and teacher training programs. in our case, we found that the "free-fall" module, which is more aligned with the middle-school curriculum, has a better chance to be implemented than the oscillations module. another way that may be useful for streamlining the learning module is by embedding the programming activities in a learning management system such as moodle. in the workshop, teachers had to split their attention between a paper worksheet, and the vpython code on the computer. in a revised version of the module that was created to support teachers in distance teaching during the covid-19 shutdown, we embedded the vpython code within an online worksheet in a learning management system. this places the programming section as an integral component of the learning unit, and can encourage students and teachers to use it. yet, another way to encourage teachers to implement is by maintaining a professional learning community of the implementing teachers. in a learning community, teachers meet regularly to discuss their successes and challenges in implementation during the school year. this supplements the summer workshop, where teachers experienced most of the learning module as students, and did not have opportunities to rehearse them as teachers. at first, we used a model of individual teacher support that included planning sessions and classroom observations with the pd team. this model of support was only partially successful, since it prevented teachers from sharing stories and reflecting on their implementation challenges with their peers. promising results from studies of professional learning communities of teachers suggest that they have a better chance to induce changes in teaching and increase teaching self-efficacy (akerson et al. 2009; lakshmanan et al. 2011 ). conflict of interest the authors declare that they have no conflicts of interest. ethical statement this research was conducted with compliance of the rules mandated by our institution's internal review board (irb) and received the approval of the chief scientist of the ministry of education in our country. consent statement all of the data sources were consenting adults. all of the subjects in this study were teachers who responded to the surveys by will, and agreed to be video recorded. understanding student computational thinking with computational modeling fostering a community of practice through a professional development program to improve elementary teachers' views of nature of science and teaching practice first-year physics students' perceptions of the quality of experimental measurements self-efficacy: the exercise of control no silver bullet for inquiry: making sense of teacher change following an inquiry-based research experience for teachers innovative uses of video analysis. the physics teacher computational physics in the introductory calculus-based course all other things being equal: children' s acquisition of the control of variables strategy stable solutions using the euler approximation the integration of computer simulation and learning suppojrt: an example from the physics domain of collisions physical and virtual laboratories in science and engineering education using computer simulations for promoting modelbased reasoning: epistemological and educational dimensions methodology and epistemology of computer simulations and implications for science education changing minds: computers, learning, and literacy the modelling framework for experimental physics: description, development, and applications using introductory labs to engage students in experimental design the role of models in physics instruction learning to interpret measurement and motion in fourth grade computational modeling should students design or interact with models? using the bifocal modelling framework to investigate model construction in high school science what makes professional development effective? results from a national sample of teachers professional development for technology-enhanced inquiry science modeling instruction in mechanics introductory physics labs: we can do better c2stem: a system for synergistic learning of physics and computational thinking reasoning from data: how students collect and interpret data in science investigations dual space search during scientific reasoning fertile zones of cultural encounter in computer science education what is scientific thinking and how does it develop the impact of science content and professional learning communities on science teaching efficacy and standards-based instruction extending the boundaries of high school physics: talented students develop computer models of physical processes in matter the influence of core teaching conceptions on teachers' use of inquiry teaching practices k-12 science and mathematics teachers' beliefs about and use of inquiry in the classroom a hybrid approach for using programming exercises in introductory physics teaching scientific practices: meeting the challenge of change evaluating a course for teaching introductory programming with scratch to pre-service kindergarten teachers what makes professional development effective? strategies that foster curriculum implementation problematizing as a scientific endeavor learning to code or coding to learn? a systematic review student programming in the introductory physics course: muppet scaffolding complex learning: the mechanisms of structuring and problematizing student work the rise of the digital polymath: switzerland is crossing the computer science education chasm through mandatory elementary pre-service teacher education vpython: 3d interactive scientific graphics for students a comparison of programming languages and algebraic notation as expressive languages for physics dynaturtle revisited: learning physics through collaborative design of a computer model prospective physics teachers' self-efficacy beliefs about teaching and conceptual understandings for the subjects of force and motion the differential antecedents of self-efficacy beliefs of novice and experienced teachers sources of self-efficacy: four pd formats and their relationship to self-efficacy and implementation of a new teaching strategy teacher efficacy: its meaning and measure how to help teachers develop inquiry teaching: perspectives from experienced science teachers model construction as a learning activity: a design space and review evobuild: a quickstart toolkit for programming agent-based models of evolutionary processes a summary of researchbased assessment of students' beliefs about the nature of experimental physics science in the age of computer simulation model-based reasoning in the physics laboratory: framework and initial results publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-284648-yznlgzir authors: varanko, anastasia; saha, soumen; chilkoti, ashutosh title: recent trends in protein and peptide-based biomaterials for advanced drug delivery date: 2020-08-29 journal: adv drug deliv rev doi: 10.1016/j.addr.2020.08.008 sha: doc_id: 284648 cord_uid: yznlgzir nan they also increase the occurrence of dose-dependent side effects. the lack of target specificity made it impossible to deliver a therapeutic to the organ of interest without impacting other cells, which caused off-target toxicity. in the 1950s, scientists began to focus on developing drug delivery systems (figure 2) . in the next thirty years, they established the principles of drug diffusion, dissolution, and pharmacokinetics [11, 12] . research then shifted toward prolonging drug release and increasing the drug's retention time in circulation [11] . scientists also focused on how to specifically deliver drugs to a disease site by engineering systems for local drug release, passive drug accumulation in the diseased tissue, and active targeting [12] . this research led to the first fda approval of a drug delivery system -liposomal amphotericin b-in 1990 for treatment of fungal infections [13] . since then, controlled delivery has been leveraged to improve the bioavailability and efficacy of numerous therapeutics [14] . biomaterials have been critical to the success of drug delivery systems. many drug formulations employ biomaterials to extend the therapeutic window by both sustaining its release from the formulation and slowing its elimination from the body. beginning in the late 1960s, scientists used synthetic materials, especially polymers, as drug carriers [11, 12] . these systems successfully extended the drug's circulation time by increasing its molecular weight to slow renal excretion. biodegradable systems were also engineered to prolong drug release, thus reducing the frequency of administration [15] . despite these accomplishments, synthetic materials can have high immunogenicity or toxic degradation products [16] . furthermore, there is limited control over the stereochemistry, structure, and molecular weight of synthetic polymers, which impacts the drug's biodistribution and pharmacokinetics [17, 18] . the production of synthetic polymer drug carriers can be difficult and expensive to scale up [19] . figure 6 : conjugation of the cyclic pentapeptide crgdfk and the photodynamic agent chlorin e6 (ce6) to sf was achieved using a simple acid-amine coupling reaction and the resulting conjugate was doped with 5-fluorouracil (5-fu) using genipin peptide as a crosslinker. adapted with permission from [84] . the adaptable mechanical properties and thermal stability of sf make it an ideal candidate material for forming hydrogels and scaffolds. its degradation can be tuned by controlling the self-assembly of sf which can stably encapsulate the therapeutics and release them on demand. kaplan and colleagues have extensively studied the abilities of sf and its hybrids to form hydrogels. they developed a method to synthesize a thixotropic silk nanofiber hydrogel from aqueous solution, which otherwise requires an organic co-solvent [85, 86] . the injectable nanofiber hydrogel stably entraps dox, solidifies in situ, and demonstrates ph-triggered sustained release of dox [86] . kaplan et al. also used an injectable sf-hydrogel system to sustain the delivery of anti-vascular endothelial growth factor (anti-vegf) therapeutics [87] , and small molecule drugs [88] . however, the prolong gelation time (weeks-months) of sf hydrogel acts as a major roadblock for their practical application. to decrease the gelation time gong et al. synthesized another class of thixotropic hydrogels by blending regenerated sf and hydroxyl propyl cellulose (hpc), a natural cellulose ether approved by fda [89] . hpc has lower critical solution temperature (lcst) of about 40 °c above which it precipitates in water. the j o u r n a l p r e -p r o o f hpc-sf blend gelled at 37 °c within 1 h. results from confocal laser scanning microscopy (clsm), raman spectroscopy, and 13 c-nmr spectroscopy suggested that the conformational transition of sf from random coil to β-sheet during phase separation resulted in gel formation through β-sheet crosslinking and immobilization of the molecules of sf and hpc in the dispersed phase. the blended hydrogel encapsulated mice fibroblasts and protected them against high shear force during injection, which suggests that the hydrogel can be used for cell delivery [89] . germershaus et al. developed heuristics to decipher protein interactions with sf using protamine and polylysine as model proteins [90] . the author concluded that the interaction between protein and sf arises primarily from entropy-driven complex coacervation, which depends on the ionic strength of the solution and presence of kosmotropic and chaotropic salts. sf-hydrogels have also been fabricated with various nanoassemblies including sfnps, carbon nanotubes and hybrid nanoparticles of different materials. mao and colleagues encapsulated curcumin-loaded cationic nanoparticles of rrr-α-tocopheryl succinate-grafted-εpolylysine conjugate into a sf-hydrogel, which promoted the penetration of curcumin into the thickening corneum of psoriatic mice and thus inhibited skin inflammation. compared to 49% of curcumin released from the nanoparticle, only 30% was released from the mixed hydrogelnanoparticle system. the author concluded that this slow release of curcumin might be due to adherence of the nanoparticles into the sf hydrogel, making it difficult for the embedded curcumin to diffuse out of the gel. this delayed release profile resulted into significant accumulation of curcumin in the stratum corneum at the 48 h [91] . wu et al. incorporated salinomycin and paclitaxel-loaded sf-nanoparticles into a sf hydrogel to inhibit cancer stem cell and tumor growth. the dual drug-loaded hydrogel had homogeneous drug distribution and exhibited increased tumor inhibition compared to the single drug-loaded hydrogel, as evidenced by fewer cd44+cd133+ tumor cells in vivo. because paclitaxel and salinomycin interacted differently with sf, their release profiles were different, with paclitaxel showing sustained release and salinomycin an initial burst release [92] . gangrade et al. introduced carbon nanotubes into sf hydrogels to construct an on-demand, tumor-targeting system [93] . they synthesized folic acid functionalized, dox-loaded, single-walled carbon nanotubes (swcnt) and incorporated them into an sf hydrogel matrix. only 7% of dox was released from the composite material over a period of five days under physiological conditions. however, intermittent exposure to near-infrared light stimulated on-demand dox release (~15%) due to the photothermal property of swcnt. he et al. developed an injectable silk fibroin nanofiber hydrogel system complexed with upconversion nanoparticles and nano-graphene oxide (sf/ucnp@ngo) for upconversion luminescence imaging and photothermal therapy [94] . the naluf 4 :er 3+ ,yb 3+ upconversion j o u r n a l p r e -p r o o f nanoparticles were complexed with the nano-graphene oxide and then doped into an aqueous sf solution to form a hybrid hydrogel system. sf/ucnp@ngo hydrogels efficiently ablated 4t1 breast cancer cells via the photothermal effect both in vitro and in vivo. recombinant techniques can also be utilized to modulate the properties of silk-based scaffolds and hydrogels. anderson et. al. recombinantly synthesized slp segments conjugated to a human fibronectin segment and cell attachment domain [95] . crystal structure characterization of (gagags)-based slps revealed the hydrophobic domains of silk collapsed to form anti-parallel β-sheets that assembled into crystallite whiskers at the nanometer scale. this self-assembled material is mechanically tough, can undergo processing in the presence of bioactive molecules, and can be processed for into thin films, hydrogels, and three-dimensional scaffolds. schacht et al. fabricated highly porous foams made from recombinant spider silk protein eadf4(c16) and a variant containing an rgd motif using a salt-leaching technique [96] . in contrast to other salt-leached silk scaffolds, the swelling behaviors of these scaffolds as measured by discovery v20 stereomicroscope were low, and the mechanical properties were suitable for soft tissue engineering. the compressive moduli of the foam in a hydrated state was 3.24 ± 1.03 kp at a protein concentration of 8% (w/v). the pore size and porosity of the foams were optimized by altering the salt crystal size, thus rendering them suitable to adhere and culture fibroblasts. as silk fibroin can self-assemble into hydrogels from an aqueous solution, it has been widely used for ocular delivery of various drugs ranging from small molecules to antibodies and other therapeutic proteins. in one such example, silk hydrogel formulations of bevacizumab, a clinically used antibody as angiogenesis inhibitor showed sustained release of the antibody over a three months' period in an intravitreal injection model in dutch-belted rabbits [87] . the bevacizumab concentration in the vitreous humor on day 90 using hydrogel formulation at both standard (1.25 mg /50 µl injection) and high dose (5.0 mg /50 µl injection) was equivalent to the levels achieved with positive control on day 30 (1.25 mg bevacizumab/50 µl injection). [87] . this concentration is estimated to be the therapeutic threshold based on the current dosage of 1 injection/month. these gels also got degraded after 3 months, indicating a repetitive dosing may be possible. additionally, the propensity of sf to bind positively charged molecules through electrostatic interaction can be exploited for topical drug delivery on the eye surface. dong et al. electrostatically coated an ibuprofen-encapsulated liposome of cationic lipids with sf for ocular drug delivery [97] . the sf being a potential mucoadhesive biopolymer aided in retention of the drug on eye surface and facilitated its sustained release. recently a phase ii clinical trial within the protein. additionally, disulfide bonding, electrostatic interactions, and hydrogen bonding provide keratin with mucoadhesive properties, which make it a useful material for delivery of drugs to the gastrointestinal tract [101] . furthermore, keratins have been employed as -smart‖ materials for stimulus responsive drug delivery. the large number of carboxyl groups within their sequence makes them phsensitive so that in response to an increase in ph, release their cargo in a controlled manner as these groups become deprotonated [102] . additionally, their rich cysteine content renders them redox-responsive. tuning the number or level of crosslinking of disulfide bonds within the protein alters the duration of drug release from a keratin-based material. similarly, keratin is responsive to changes in glutathione (gsh) concentration. this is particularly useful for delivery of chemotherapeutics to metastatic cancer cells, which have significantly higher concentrations of gsh than healthy cells. moreover, the high lysine and arginine content in some keratins enables their cleavage by high concentrations of trypsin [103] , which is frequently overexpressed in inflamed tissue [104] . thus, keratin could be a useful material when targeting injured or tumorous tissues. due to its unique material properties, keratin has been used to create nanoparticles that encapsulate and sequester a therapeutic cargo before releasing it in response to biological stimuli. these nanoparticles can stably carry therapeutics via electrostatic interactions, hydrogen bonding, disulfide bond formation, or chemical conjugation. keratins are durable and remain stable in the bloodstream, which increases the half-life of its cargo [100] . positively charged drugs electrostatically adsorb to the surface of negatively charged keratin nanoparticles; this interaction provides long-term, sustained release of the drug from its carrier. zhi et al. first explored this strategy by complexing the model drug chlorhexidine (chx) with keratin nanoparticles generated by ionic gelation [102] . carboxylate groups on the nanoparticle surface stabilized the polyanion complex with chx. this interaction provided a remarkable chx encapsulation efficiency of 91.2% and a loading content of 9.2%. zhi et al. demonstrated that for 140 hours, the drug was released in a ph-dependent manner with greater release observed at neutral and slightly acidic ph, which indicates the utility of this system to deliver chemotherapeutics to the acidic tumor microenvironment [102] . can be loaded with dox via electrostatic interactions [105] . these nanoparticles were designed to exploit keratin's responsiveness to ph and glutathione concentration to release the drug, which is a useful strategy to treat solid tumors, which have a ph of 6.2-6.9 and gsh concentration of 0.5-10 mm, which is approximately 10-fold greater than the gsh concentration of healthy tissue [105] . kdnps were created with a desolvation method that destabilizes keratin with ethanol and causes it to aggregate into nanoparticles that are crosslinked with glutaraldehyde. in an environment with a low ph or high concentrations of glutathione, kdnps experienced a stark increase in zeta potential and underwent a negative-to-positive charge conversion. the positive charge facilitated internalization by cells and electrostatically repelled the drug, thus accelerating its release (figure 7) . error! reference source not found.moreover, the charge conversion destabilized the nanoparticles, causing them to aggregate and accumulate at the tumor due to the enhanced permeation and retention (epr) effect, which further enhanced their anti-cancer potency [105] .the stimulus-responsive properties of kdnps were expanded by li et al., whoe engineered triple stimuli-responsive kdnps via drug-induced ionic gelation. in addition to releasing dox in response to changes in ph and glutathione concentration, these nanoparticles broke down in the presence of high concentrations of trypsin, which digested the peptide bonds within the keratin [106] . similarly, keratin graft poly(ethylene glycol) nanoparticles have also been explored as glutathione-responsive vehicles; dox-hcl entrapped in the disulfide-crosslinked keratin core was released in response to increased intracellular glutathione concentrations [107] . due to its exquisite and versatile loading capacity, keratin has also been harnessed to create bimodal nanoformulations that combine chemotherapeutics and photodynamic therapy. martella et al. functionalized high molecular weight keratin with the photosensitizer chlorin-e6 (ce6) and induced spontaneous nanoparticle formation by mixing the protein with paclitaxel, a chemotherapeutic that aggregates with the hydrophobic residues in keratin [108] . this is an attractive bottom-up nanoparticle fabrication strategy, as it did not require any toxic crosslinkers or downstream purification steps for nanoparticle fabrication. when administered to an osteosarcoma cell line, the nanoparticles localized to the cell lysosome. although ce6 typically experiences a drop in fluorescence in acidic conditions, the keratin protected the photosensitizer and no decrease in fluorescence was observed. further, the nanoparticle formulation j o u r n a l p r e -p r o o f transported the paclitaxel in a three-dimensional tumor model system without reducing the drug's potency [108] . keratin nanoparticles have also been engineered for mucoadhesive drug delivery. kerateine (ktn) and keratose (kos) are two forms of keratin that have been extracted and processed in its reduced and oxidized forms, respectively. cheng et al. demonstrated that, by altering the ktn:kos ratio, the mucoadhesive properties and thus drug release, gastric retention time, and bioavailability of keratin nanoparticles could be tuned [109] . an evaluation of the hydrophobicity, surface charge, and terminal groups of the nanoparticles revealed that the mucoadhesive properties of ktn were dominated by electrostatic interactions, whereas those of kos were primarily due to hydrogen bonding with gastric mucin. moreover, cheng et al. discovered that gastric retention time decreased with an increase in kos, and release of the model drug, amoxicillin, increased with a larger proportion of ktn due to its ph responsiveness [109] . keratin-based films have been widely explored for biomedical applications due to the presence of cell attachment sites, their biocompatibility, and their large surface area. these mechanically and chemically stable materials have been useful for delivering a variety of drugs and peptides. in an early study of keratin films, fuji et al. extracted keratin from human hair in the absence of surfactant, thus creating a water-soluble film comprised primarily of α-keratins [110] . alkaline phosphatase, a model enzyme, was incorporated into the film by mixing it with the keratin prior to gelation. the biochemical properties and bioactivity of alkaline phosphatase were maintained for two weeks after loading [110] . while keratin films have excellent biocompatibility, they lack mechanical strength. thus, many studies combine keratin with other materials or treat the protein with a crosslinking agent to improve its rigidity, stiffness, and stability. in one example, keratin was blended with sf to create a composite film for the delivery of bowman-birk inhibitors (bbi), synthetic peptides designed to inhibit elastase in wound healing applications [111] . sf provided structural stability to the film while keratin governed the degradation and bbi release rates. using fitc -tagged bovine serum albumin (bsa) as a model protein, vasconcelos et al. demonstrated that, although the sf was compact and rigid, increasing the percentage of hydrolytic keratin could increase the rate of fitc-bsa release by film degradation and diffusion [111] . another study used transglutaminase (tgase) to crosslink keratin films to improve the mechanical strength and chemical stability of the material [112] . treatment with tgase resulted in more compact network correlated with the amount of iodoacetamide used, though it was not directly proportional due to the binding affinity of the model drug to the keratin [116] . a disulfide shuffling strategy was used by cao et al. to explore how disulfide bond formation impacts drug release. they cleaved intramolecular disulfide bonds with a reductive agent (e.g., cysteine) to free thiol groups that could then form intermolecular disulfide bonds ( figure 8a ) error! reference source not found. [117] . this tactic increased the mechanical strength of the hydrogel, reduced its gelation time, and required a lower amount of keratin for gelation. the release rates of ciprofloxacin and dox were inversely proportional to the level of cysteine in the hydrogels. hydrogels that entrapped ciprofloxacin also demonstrated zero-order release kinetics in pbs (figure 8b & c) . moreover, when these hydrogels were exposed to increasing concentrations of glutathione, the degradation rate increased in response to the more rapid degradation of disulfide bonds ( figure 8d & e) [117] . these studies indicate that the degradation rate of keratin hydrogels can be altered for specific disease states and drugs. ph-responsive keratin hydrogels have also been designed to reversibly swell in response to their environment to modulate the release of their cargo. in many of these examples, keratin has been combined with itaconic acid, n-isopropyl acrylamide, or methacrylic acid to achieve ph responsiveness [118] [119] [120] . more recently, peralta ramos et al. reported a stimulus-responsive hydrogel that did not depend on chemical grafting to achieve its mechanical properties and phresponsivity [121] . this was credited to a novel synthesis strategy during which disulfide bridges were broken and the α-keratin reorganized. at an acidic ph, the carboxyl groups were protonated and formed hydrogen bonds, which created a higher fraction of β-sheet conformations and kept the gel in a collapsed state. at a basic ph, hydrogen bonds broke to create more sites for water adsorption, thus forcing chain reorganization and allowing the material to swell [121] . villanueva et al. expanded upon this work by incorporating antimicrobial zno nanoplates into the ph-responsive hydrogel [122] . upon administration to a chronic wound, the hydrogel swelled in response to the basic environment and locally released the biocidal agent. as the wound healed and the presence of microbes decreased, the gel collapsed and inhibited the release of zno [122] . this study demonstrates how keratin hydrogels can be used to adjust the delivery of a therapeutic agent in response to alterations in ph. albumin is the most abundant protein in human plasma and has a set of properties that make it a unique molecular carrier for drugs: (i) it is a natural physiological carrier of native ligands and nutrients; (ii) it bypasses systemic clearance and degradation by the body's own innate mechanisms, so that it has an exceptionally long half-life of 19 days in humans, and similarly long half-lives in most animal species [123] [124] [125] [126] ; (iii) it preferentially accumulates at sites of vascular leakiness; (iv) it is highly internalized and metabolized by rapidly growing, nutrient-starved cancer cells; and (v) it is biodegradable and has no known systemic toxicity. because of these properties especially its extraordinarily long plasma circulation, albumin has attracted a lot interest as a carrier for diverse drugs. three naturally derived albumin molecules have been used to address the delivery challenges associated with small molecule drugs. ovalbumin (ova), a highly functional food protein with a molecular weight of 47 kda and isoelectric point (pi) of 4.8, is a monomeric phospho-glycoprotein consisting of 386 amino acid residues [127] . each ova molecule has one internal disulfide bond and four free sulfhydryl groups. ova was originally chosen as a carrier for drug delivery because of its availability, low cost, ability to form gel networks and stabilize emulsions and foams, and ph-and temperature-sensitive properties [128] . bovine serum albumin (bsa), which has a molecular weight of 69 kda and a pi of 4.7 in water (at 25 °c), has also been widely used for drug delivery because of its abundance, low cost, ease of purification, unusual ligand-binding properties, and wide acceptance in the pharmaceutical industry [129] [130] [131] [132] [133] [134] . however, due to possible human immunologic response to ova and bsa in vivo, human serum albumin (hsa) is now exclusively used for drug delivery [50] . hsa, which has a mw of 66.5 kda, is the most abundant serum protein with a concentration of 30-50 g/l in human serum. it is long-circulating with an exceptionally long in vivo half-life of ~19 days [123] [124] [125] 135] . about 10-15 g of albumin is synthesized by liver hepatocytes daily and released into circulation [136] . when albumin extravasates into tissue, it is naturally recycled and returned to the vascular space via the lymphatic system. the same approximate mass of 10-15 g of albumin entering the intravascular space is also catabolized daily. hsa is a carrier of a wide variety of endogenous and exogenous compounds and facilitates the colloidal solubilization and transport of j o u r n a l p r e -p r o o f hydrophobic molecules, such as long chain fatty acids, and variety of other ligands, including bilirubin, hormones, amino acids, metal ions, and drugs [136, 137] . hsa is a soluble, globular, monomeric protein consisting of 585 amino acid residues. it contains 35 cysteinyl residues that form one sulfhydryl group and 17 disulfide bridges [123, 135, 138] . figure 9a shows the crystal structure of albumin and the sites where ligands can bind [139] . three distinct features of albumin make it ideal for use in drug delivery applications: binding, trafficking, and recycling. binding: each class of drugs has a distinct binding affinity to different binding sites of albumin. dicarboxylic acids and sterically demanding anionic heterocyclic molecules (e.g., warfarin) bind to sudlow's site i (figure 9a ), whereas aromatic carboxylic acids with a single negatively charged acid group separated by a hydrophobic center (e.g., diazepam, ibuprofen) bind to sudlow's site ii [140] . hsa has seven long-chain fatty acid binding sites (fa1-7 in figure 9a , asymmetrically distributed throughout its three domains) that promote binding of up to two moles of fatty acid per mole of hsa under normal physiological condition [141] [142] [143] . compounds with p-isothiocyanate (p-scn) or nhs ester (n-hydroxysuccinimide) functional moieties covalently react with albumin's lysine, with lys199 residue being the most reactive [144, 145] . however, due to multiple other (at least ten) surface accessible lysine residues in hsa, reaction with lysine residues leads to poorly defined conjugates with a range of stoichiometries [146, 147] . alternatively, the solvent accessible cysteine34 in hsa can be selectively modified with a prodrug containing a maleimide functionality, as (i) 70% of circulating serum albumin possess one free cysteine; (ii) other major serum proteins lack a solventaccessible free cysteine; and (iii) the 34 th cysteine residue of albumin (pk a ~ 7) has the most reactive thiol group in human plasma [144, 148] . trafficking: albumin naturally transcytoses across the vascular endothelium, which normally creates an impermeable barrier to most plasma proteins. this process is attributed to the 60 kda vascular endothelium receptor sialoglycoprotein (gp60). albumin binds to gp60 and forms a cluster in association with cav-1, the main protein critical to caveolae formation. clustered albumin-gp60 receptors and compounds bound to albumin are then internalized and transported to the basolateral membrane to complete transcytosis [149] . interestingly, modified albumins show preferential binding to gp18 and gp30 [150] . preferential internalization of albumin in cancer cells has also been correlated with albumin binding to sparc (secreted protein acidic and rich in cysteine). for example, immunohistochemical staining detected stromal j o u r n a l p r e -p r o o f sparc in ∼70% of non-small cell lung cancer (nsclc) cases, and increased chemotherapeutic efficacy of albumin-bound paclitaxel was correlated with high stromal sparc reactivity of nsclc cells [151] . recycling: the long half-life of albumin is attributed to the neonatal fc receptor (fcrn), a widely distributed intracellular receptor responsible for salvaging albumin from cellular catabolism [143] . fcrn binds to albumin in the acidic endosome, diverts it from the lysosomal degradation pathway, and the complex is exocytosed. albumin is released from fcrn at extracellular ph and enters circulation through the lymphatics, thus prolonging its half-life. albumin also avoids renal clearance by reabsorption through megalin and cubilin receptormediated endocytosis in the renal proximal tubule. in situ albumin-binding drugs have been designed to covalently react with or noncovalently bind to endogenous albumin, which capitalizes on the long-circulating property of the protein to enhance the pk and hence pd of the drug. indeed, exploitation of endogenous serum albumin has several advantages over the use of exogenous albumin: first, although commercial exogenous albumin can be isolated with high yield and purity, it is often contaminated with pathogens. second, the cost, effort, and time required for manufacturing exogenous albumin is altogether avoided. third, as no external macromolecular carrier is involved, the quality control associated with endogenous albumin is comparable to small molecule drug candidates. irreversible covalent bond formation between endogenous albumin molecules and a therapeutic payload can be utilized to enhance the pharmacokinetics of the latter. kratz et al. pioneered this strategy by synthesizing a prodrug that selectively reacts with the 34 th cysteine residue of circulating serum albumin after systemic administration, which improves the drug's plasma half-life and protects it from premature degradation. the therapeutic cargo (e.g., dox) was anchored with a thiol reactive maleimide group via a ph-sensitive hydrazone bond and a carefully optimized alkyl spacer. upon intravenous injection, the highly reactive maleimide group formed an irreversible thioether bond with the thiol group of the albumin. the ph-sensitive hydrazone bond facilitated the liberation of the covalently attached dox from albumin after en endocytosis by cells. aldoxorubicin, also known as dox-emch (figure 9b & c) is currently j o u r n a l p r e -p r o o f under various phases of clinical trial for the treatment of soft tissue sarcomas (nct01673438 and [152] ) and small cell lung cancer (nct02235688). inspired by dox-emch, many other albumin-binding prodrugs have been developed. these prodrugs often consist of an anticancer drug, a maleimide group as the thiol-binding moiety, and a cleavable linker [144] . native albumin-binding ligands such as fatty acids can be directly conjugated to therapeutics, which results in docking of the drug to endogenous albumin upon systemic administration. a notable example of this class is semaglutide, an fda approved drug that is a glucagon-like peptide-1 (glp-1) analog with an octadecyl fatty diacid conjugated to the epsilon amine of a lysine residue in the peptide via a glutamyl ethylene glycol spacer [153] . the plasma half-life (t 1/2 , seven days in humans) and glp-1 receptor (glp-1r) binding affinity (k d ~ 0.38 nm) of semaglutide make it suitable for once-weekly administration for treatment of type 2 diabetes [153, 154] . this was an important advancement, as its predecessor liraglutide -which contains a hexadecyl monoacid conjugated to the same lysine residue of glp-1 via a γ-glutamic acid spacer-has a t 1/2 of only 0.5 days in humans, and is hence only approved for once-daily treatment of type 2 diabetes, despite having a three-fold higher affinity for glp-1r (k d ~ 0.11 nm) than semaglutide. this dramatic improvement was attributed to both the spacer and ligand chemistry of the glp-1 analog in semaglutide, which influenced in vivo albumin binding [153] . other therapeutic payloads are bound to endogenous hsa by conjugation of the drug to fatty acids through various cleavable linkers [125, 144] . synthetic small molecules can also bind endogenous albumin [144] . most drugs and small molecules that interact with hsa are anionic, although a few cationic drugs have detectable affinity [142] . evans blue (eb), an aromatic dye with four anionic charges, reversibly binds to serum albumin with a micromolar affinity. the affinity of eb for albumin allows 100% of the injected dose to be retained in the blood; thus, it can be used to quantify total plasma volume of a test subject [155] . albumin-bound eb can also be used to assess blood brain barrier (bbb) permeability, as the bbb is impermeable to the complex in healthy, non-pathological conditions [156] . eb derivatives with various affinities to albumin have been used to deliver therapeutic cargo [144, 157] . yamamoto et al. developed an o-toludine eb analogue that chelates gadolinium (iii), as a t 1 -weighted mri contrast agent for imaging of blood vessels [158] . labeling with different pet isotopes (e.g., 68 ga, 64 cu) [159] [160] [161] . chen et al. evaluated labeled neb in mice as a blood pool imaging agent under various pathological conditions, including myocardial infarction (mi) and serum leakage from permeable or abnormal blood vessels. sentinel lymph nodes (slns) were visualized in all 24 pathologically diagnosed breast cancer patients within 4.0−10.0 (5.6 ± 1.4) min [161] . by analyzing 68 ga-neb pet/ct images. to identify molecular features required for albumin binding, the neri group screened a dnaencoded chemical library comprising >600 oligonucleotide-conjugates of potential albumin-binding molecules coded with unique six-base-pair sequences for identification [162] . the hsa-binding tags were chosen through systematic evolution of ligands by exponential enrichment (selex). the selection, amplification, and microarray analysis of the pool suggested that following structural features are important for albumin binding: (i) the presence of a 4-phenylbutanoic acid moiety is essential; (ii) a butanoyl acid moiety increases albumin affinity as propanoyl and pentanoyl acid residue was not enriched in the pool; and (iii) substitution at the para position of the phenyl ring with a hydrophobic functionality increases the affinity towards albumin. albumin-binding domains (abds) are small protein domains that non-covalently associate with serum albumin. abds are structurally robust and stable, as evidenced by their ability to withstand denaturation at extremely low ph (2.4) and high temperatures. and have also been explored for drug delivery. abds are used for drug delivery by either fusion with a therapeutic protein at the gene level if the protein is recombinantly produced or are chemically synthesized to conjugate small molecule drugs for systemic administration. sjöbring and colleagues isolated a 14-kda albumin binding protein fragment from streptococcal protein g. this 46-amino acid native abd (abdn) is a 3-helix bundle and has nanomolar affinity for hsa [163, 164] . using abdn as a template, jonsson et al. identified an engineered version of abdn from a phage library. specifically, they targeted 15 residues in a combinatorial protein engineering strategy to identify an albumin -binding sequence with improved hsa affinity. the high -affinity abd (abdh) has superior thermal stability and binds hsa with femtomolar affinity. chilkoti and colleagues recombinantly fused abdn and abdh to the n-terminus of a hydrophilic, thermally responsive chimeric polypeptide (cp) that contained multiple c-terminal cysteine residues [126] . the recombinant polypeptides formed highly monodisperse micellar nanoparticles upon covalent conjugation of multiple copies of hydrophobic dox molecules to the cysteine residues through the ph-sensitive hydrazone bond (using maleimide-thiol chemistry) ( figure 10a) . the dox-loaded abdn/abdh-decorated polypeptide micelles -termed abd-j o u r n a l p r e -p r o o f journal pre-proof cp-dox-bind both human and mouse serum albumin with high affinity, as seen by native page and isothermal titration calorimetry (figure 10b & d) . hence, upon systemic injection, they instantaneously bind endogenous albumin with high affinity and are coated with an albumin corona. the albumin decorated abd-cp-dox nanoparticles had significantly superior pk in both murine and canine models compared to a negative control, cp-dox nanoparticles that do not present abd domains on the surface of the nanoparticle (figure 10e & f) the long plasma circulation of the abd-cp-dox nanoparticles also resulted in higher accumulation in tumors than the cp-dox nanoparticles, and these nanoparticles also showed better tumor regression, and a wider therapeutic window than the cp-dox nanoparticles. these results clearly show the enhancement in pk and pd conferred by decorating a drug-loaded nanoparticle with endogenous albumin. furthermore, the same group took advantage of the native sortase reaction to directly install dox onto the abd (abd-dox) through a ph-sensitive linker, without forming nanoparticles [59] . abd-dox bound to both human and mouse serum albumin with nanomolar affinity, had a terminal t 1/2 of 29.4 h in mice, and increased tumor accumulation by ~120 fold compared to free dox ( figure 11a ). in multiple mouse xenograft models, abd-dox resulted in greater tumor regression than aldoxorubicin, dox-prodrug under clinical development that was designed to covalently bind endogenous serum albumin. other notable examples of albumin-based delivery systems involve the genetic fusion of abd to various therapeutic proteins including affibodies [165, 166] , human soluble complement receptor type 1 [167] , single chain antibody-drug conjugates [168] , insulin-like growth factor ii [169] , immunotoxins [170] , and respiratory syncytial virus subgroup a (rsv-a) g protein (g2na) [171] . j o u r n a l p r e -p r o o f albumin-bound therapeutics can also be formulated ex vivo with purified albumin molecules prior to administration. in contrast to other physiological proteins, albumin tolerates a wide range of ph (stable in the range of 4-9), temperatures (can be heated at 60 °c for up to 10 h), and organic solvents [50] . these properties have motivated researchers to covalently and non-covalently append various payloads, including radioisotopes (e.g., 18 f, 68 ga, 111 in) and anticancer drugs (e.g., dox, curcumin, methotrexate), to albumin for imaging and delivery purposes [125, 144] . however, modification of exogenous albumin with drugs is often associated with suboptimal drug loading, as denaturation and albumin molecule crosslinking potentially compromise its physiological behavior. smith et al. addressed these challenges by synthesizing an albumin-polymer-drug conjugate with high drug loading efficiency [172] . using a convergent, reversible addition−fragmentation chain transfer (raft) polymerization reaction, they synthesized a polymeric prodrug of panobinostat, an fda-approved anticancer agent, with hpma (n-2-hydroxypropylacrylamide). multiple copies of panobinostat were attached to the polymeric prodrug, which was then conjugated to albumin using nhs chemistry under physiological conditions, thereby minimally affecting the albumin molecule ( figure 11b ). the first albumin-drug conjugate that entered phase i/ii trial was a methotrexate-albumin (mtx-hsa) conjugate synthesized using covalent coupling between carboxylate of the mtx and lysine residues of hsa. seventeen patients not amenable to standard care were treated with up to eight injections given in weekly intervals. tumor responses were seen in three with no sign of toxicity and drug accumulation. the mtd for weekly administration was found to be 4 × 50 mg/m 2 and a injection of 50 mg/m 2 every 2 weeks was recommended for a further study [173] . however, in a subsequent phase ii study no objective responses were seen, although eight patients did not have disease progression (stable disease) for up to 8 months (median 121 days) [174] . a phase ii study showed combination of mtx-hsa with cisplatin as an effective treatment modality against urothelial carcinomas with an acceptable toxicity profile [175] . patients were treated with a loading dose of 110 mg/m 2 of mtx-hsa followed by a weekly dose of 40 mg/m 2 starting on day 8. tumor response was observed in 7 patients. complete response (cr) and partial response (pr) was observed in 1 patient each (overall response rate: 29%) but no follow up clinical investigation was undertaken. paclitaxel, an fda approved paclitaxel formulation for the treatment of multiple cancer types [176, 177] . abraxane was developed by american bioscience using the so-called nab-technology in which paclitaxel and human serum albumin are passed through a jet under high pressure to form nanoparticles with a mean diameter of 130 nm. several albumin nanoparticle of small molecule drugs has been developed using nab technology and are under various phases of clinical trials [178] . nab-rapamycin is currently under phase i clinical trial to treat non-muscle invasive bladder cancer (nct02009332) and under phase ii clinical trial to treat progressive high-grade glioma (nct03463265). nab-docetaxel proved to be effective against hormone refractory prostate cancer (nct00477529) and metastatic breast tumors (nct00531271). nab-5404, a novel albumin formulation of thiocolchicine dimer exhibits dual inhibition of tubulin polymerization and topoisomerase i activities. it showed antiangiogenic and vascular targeting activities and was found to be effective against solid tumors and lymphomas (nct01163071). lin et al. reported a method to simultaneously encapsulate paclitaxel by denaturing albumin with sodium borohydride at high urea concentration, followed by addition of hydrophobic drugs to the denatured protein, and diluting the mixture to spontaneously refold albumin and form nanoparticles [179] . this method avoids chemical crosslinkers and high-pressure emulsification techniques. by adding a cell-penetrating peptide to the dual drug-loaded albumin nanoparticles, they achieved bbb penetration through interaction with sparc, which resulted in greater survivability in a u87 orthotopic glioma model [179] . albumin has also been derivatized into a diblock format in which a hydrophilic albumin block gets exposed at the surface of the hybrid nanoparticle and a synthetic hydrophobic polymer, such as polycaprolactone, forms the core. to achieve this, jiang et al. synthesized two different polymers based on ring-opening polymerization: poly(oligo-(ethylene glycol) methyl ether acrylate)-poly(ε-caprolactone) (poegma-pcl) and maleimide-functionalized polycaprolactone (mi-pcl). mi-pcl was conjugated to the free cysteine on bovine serum albumin (bsa-pcl) [180] . the authors formulated hybrid nanoparticles by co-assembling poegma-pcl, bsa-pcl, and curcumin with increasing albumin content. cellular uptake of the nanoparticles in cancer cell lines increased with albumin content [120] . additionally, albumin nanoparticles can be decorated with targeting ligands, such as mannose [181] , folic acid [182] , antibodies [183, 184] , and aptamers [185] , to provide greater receptor specificity. recombinant albumin is another alternative to animal-derived albumin and is increasingly being used in exogenous formulations. direct genetic fusion to recombinant albumin enables one-step fabrication of therapeutic proteins. for instance, rlx-fp, a genetically encoded fusion protein linking recombinant human albumin with human coagulation factor ix, has a 5-fold longer j o u r n a l p r e -p r o o f plasma half-life than unmodified coagulation factor ix (fix) products. an advanced phase iii clinical trial (prolong-9fp) demonstrated the long-term safety, tolerability, and efficacy of rix-fp for prophylactic and on-demand treatment of bleeding episodes in children [186] . li et al. synthesized an albumin-lidamycin conjugate by recombinant dna technology. lidamycin, a cyclic enediyne antibiotic is ~1000 fold more potent than dox against multiple cultured cancer cell line and it consists of an apoprotein (ldp) and an enediyne chromophore (ae) that can be separated and reassembled in vitro [187] . a dna fragment encoding hsa-ldp was constructed and the fusion protein was purified from pichia pastoris using imac. the hsa-ldp conjugate was then reconstituted with the ae to form the albumin-lidamycin conjugate that had a sub nanomolar ic 50 value in various cancer cell lines, significant tumor retention , and potent in vivo tumor regression efficacy against mouse hepatoma h22 model [188] . other recombinant albumin proteins include genetic fusions with interleukin-2 [189] and interferons [190, 191] . albuferon® aka albinterferon-α-2b was developed as a fusion protein of albumin and interferonα-2b (infα-2b) and is under phase iii for the treatment of hepatitis c infection (nct00724776). several other phase iii trials are under progress aimed at evaluating the efficacy and safety of albinterferon-α-2b [177] . however, high-yield synthesis of pure recombinant albumin and albumin fusions requires a complex procedure and specialized yeast expression system that are not readily available to most researchers. nguyen et al. made significant progress by purifying recombinant hsa from a bacterial expression system using maltose-binding protein and protein disulfide isomerase [192] . but an optimized bacterial expression system to purify recombinant albumin is still needed. collagen is the most abundant protein in mammals, making up nearly one-third of all proteins in the body. a diverse family of structural proteins, collagen is a major component of the extracellular matrix (ecm) and connective tissue. it has a broad spectrum of functions, including cell adhesion, cell migration, tissue scaffolding, and repair [193] . to date, thirty different classes of collagen have been identified and characterized [194] , though not all are relevant for this discussion. the most abundant class of collagen -fibrillar collagen-represents more than 90% of human collagen and includes types i, ii, iii, v, and xi. this class is a major component of skin, hair, ligament, tendon, cartilage, bone, and placenta. other common types of collagens, like iv and viii, construct the network structure of basement membranes [193, 194] . before discussing their molecular architecture and biomedical applications, it is important to define the term -collagens.‖ gelatin, a thermally degraded, collagen-derived product, is also termed j o u r n a l p r e -p r o o f ‗‗collagen'' in the literature despite losing the characteristics of real collagen, and will hence be discussed separately [195] . although the molecular architectures and functions of collagens vary greatly, they all share the same tertiary structure -the collagen triple helix [196] . under the electron microscope, native collagen shows a thread-like structure -fibrilsconsisting of collagen molecules organized in three interlocking polytripeptide chains that form a triple helix , with each chain having the general sequence giy-x-y, where x and y are occupied by proline (pro) and (4r)hydroxyproline with the highest statistical frequency. each collagen polypeptide chain is twisted around a threefold screw axis and exists in a secondary structure analogous to the left-handed polyproline ii-helix. the three polyproline ii-helices are held together by hydrogen bonding, which repeats periodically between the glycine amide in one helix and the carbonyl group of the amino acid residue of the neighboring helix. the three polyproline ii-helices form a right-handed triple helix stabilized by hydrogen bonds [194, 196, 197] . with tunable self-assembly, gel-forming ability, biodegradability, and responsiveness to external stimuli, collagens have been increasingly used for drug delivery and tissue regeneration [195, [198] [199] [200] . current research is focused on developing short, bioinspired model collagens, termed as collagen-mimetic peptide (cmps) or collagen-like peptides (clps) [201, 202] . clps are short, synthetic peptides arranged in the same triple-helical conformation as native collagens. clps have been used: (i) to elucidate the triple helix structure and the molecular forces responsible for this architecture; (ii) to target pathological collagen in vivo through triple helix hybridization; and (iii) as a bioactive domain to construct smart biomaterials through hierarchical self-assembly. each of these applications will be discussed separately as they are relevant for drug delivery. to exploit clps to fabricate biomaterials, it is critical to elucidate the intrinsic parameters affecting the sequence-based thermal stability of the triple helix. in contrast to native collagen, clps exhibit reversible phase transition behavior. their slow folding rate upon denaturation and small size allow researchers to thermodynamically characterize the folding and melting processes of clps by x-ray crystallography, atomic force microscopy (afm), light scattering, and circular dichroism (cd) and nuclear magnetic resonance (nmr) spectroscopy. many researchers have synthesized and studied polypeptides with gly-x-y sequences that fold into a triple-helical structure. persikov et al. investigated the role of guest amino acid residues at the x and y positions on the thermal stability of the triple helix [203] . they documented that the guest j o u r n a l p r e -p r o o f triplets gly-x-hyp and gly-pro-y can be used to quantitate the conformational propensities of all 20 amino acids to form a triple helix at the x and y positions in a (gly-pro-hyp) 8 persikov proposed that the triple-helical structure of clps is the direct result of the propensity of amino acids to adopt a polyproline ii-like conformation, which is driven by the high propensity of ionizable residues in the x position for interchain hydrogen bonding and a low propensity of bulky residues in the y position for effective solvation. building upon this concept, many studies have deciphered the structure-function relationship of the clp phase transition [201, 202, 204] . to improve the stability of the triple-helical structure of clps, c-terminal covalent crosslinking was performed using an interchain cystine knot derived from collagen type iii [205] [206] [207] . such covalent modification also includes the crosslinking of three α-chains at the cterminus using various templates such as cis,cis-1,3,5-trimethylcyclohexane-1,3,5-tricarboxylic acid (kta) and tris(2-aminoethyl)amine-(succinate-oh) 3 (tren) [208, 209] . comparative analysis using cd and nmr spectroscopy revealed that the flexibility of the tren scaffold is superior to that of the kta scaffold for the induction of triple helicity [208] . however, to avoid cumbersome covalent crosslinking, simple noncovalent crosslinking strategies have been developed based on: (i) interchain metal bridging by functionalization of the terminus of clps with a chelating ligand [210, 211] and (ii) hydrophobic interactions using a single saturated hydrocarbon or lipid tail [212] [213] [214] . the thermal stability of the triple helix of lipid-modified clps increased as the monoalkyl chain length increased from c 6 to c 16 [214] . furthermore, introducing amino acids with guest residues that have a cγ substitution with a highly electronegative atom, such as fluorine and chlorine, in place of hydroxyproline also increased triple helix stability [215] [216] [217] [218] . it is important to note that the triple-helical structure restricts the sequence space available for synthetic clps, and until recently, was thought to be intolerant to substitution of glycine in the gly-x-y triplet. multiple recent reports have shown that modification of glycine with a thioamide, nitrogen atom, or azaglycine (azgly) yielded comparable or better stability of clps compared to their non-substituted counterparts. another recent approach incorporated metal-binding sites at the ends of clps to drive thermodynamically stable, nanomicro scale self-assemblies of various shapes [219, 220] . zheng et al. elucidated the role of surface electrostatics and hydrogen bonding on the stability of the triple helix and provided computational tools for de novo design of clps beyond the gly-x-y triplet [221] . taken together, these structure-function studies indicate that nature may not have optimized the stability of the collagen triple helix, and that there is plenty of room for further improvement through precise design of clps beyond tandem arrays of the gly-x-y triplet sequence. although the major impediment in clp research is deciphering the triple helix conformation and supramolecular assembly formation (discussed in the next section), biomedical applications of monomeric clps have gained attention in recent years using denatured collagen. degradation of the ecm is a crucial element governing the progression of tissue remodeling in many life-threatening diseases, including cancer, cardiovascular diseases, and organ fibrosis, as well as prevalent debilitating conditions, such as arthritis and intervertebral disc degeneration. during tissue remodeling, collagen molecules within the collagen fibers and networks are degraded by proteases, such as mmps or cathepsin, and denature at body temperature. in a seminal work, yu and coworkers demonstrated that unfolded, single-stranded clps with a sequence (gpo) n (where n=6-10) have a high propensity for binding denatured collagen through a -strand hybridization process‖, which is similar to the binding of complementary dna strands [222, 223] . due to the high serum stability of such collagen -hybridizing peptides [224] and their affinity for native collagen [222] , they have been used to selectively stain native collagen both in vitro and in vivo by fluorescently labeled clps [225] [226] [227] [228] [229] . fluorescently labeled clps can also target solid tumors through the triple helix hybridization process, as high mmp-9 activity in tumor tissue exposes denatured collagen [230] . because homotrimeric clps have little driving force for collagen hybridization, clps must be thermally dissociated by heating at 80 °c to the monomeric state before binding to a collagen substrate. to avoid the preheating step, the yu group developed a sequence (gfo) 9 by replacing the hydroxyproline with a fluoroproline (f) [231] . this new sequence cannot self-trimerize at body temperature but maintains the ability to hybridize with natural collagen chains. by appending an octa-glutamic acid residue at the nterminus of the (gpo) 9 , the authors attracted vascular endothelial growth factors (vegfs) to the collagen-binding site of the endothelial cells through charge-charge interactions, which resulted in tubulogenesis [232] . triple helix hybridization has also been used to impart collagen-targeting properties to nanoparticles [233, 234] and for sustained release of nucleic acids from collagen films and depots [235, 236] . recently, the hubbell lab recombinantly fused a collagen-binding domain (cbd) to interleukin-12 (figure 12) , a potent cytokine that stimulates the innate and adaptive immune system (cbd-il-12). intravenously administered cbd-il-12 preferably accumulated in the tumor stroma and provided a sustained intratumoral level of interferon-γ, thereby eliciting superior anti-tumor effects and fewer off-target toxicities when compared to naked il-12 [237] . in the past few decades, the wealth of knowledge accumulated about the structure of collagen has driven a surge in research focused on the supramolecular assembly of collagenlike peptides. in the previous section, we described how various molecular interactions can stabilize the formation of a triple helix. in this section, we delve deeper into the molecular determinants of higher-order self-assembly of clp--based biomaterials -beyond the triple helix-and how they can be used in drug delivery. we have organized this section by the specific molecular stimuli that trigger self-assembly. cysteine knot in clp self-assembly: in an early example, raines and coworkers used two cysteine knots to covalently link three clps, one of which protruded out to produce a sticky end during triple helix assembly [238] . the sticky ends forced the trimers to configure themselves in a head-to-tail fashion, which resulted in a long, single collagen triple helix. such collagen-like fibrils were much longer (400 nm) than the native type i collagen (300 nm). in a similar approach, the koide group developed a synthetic clp system in which three clps were preorganized in a staggered configuration that was locked in place by two cysteine knots [239] . cd, ultrafiltration, and laser diffraction analysis indicated that the staggered trimers formed large supramolecular architectures through intermolecular triple helix formation. however, hydrogels made of these collagen fibers did not successfully form due to concentration-dependent aggregation. to address this limitation, yamazaki et al. appended a hydrophilic arginine residue at the cysteine knotted end of the synthetic clps [240] . the disulfide-linked trimers of the gly-x-y triplet repeats formed hydrogels by spontaneous intermolecular triple helix formation upon cooling. the thermal sol-gel transition is reversible, and the design of the peptides can tune the transition temperature. koide's group also incorporated an integrin-binding sequence gfoger into one clp strand of the same knotted trimeric base unit. the supramolecular structure exhibited adhesion to human dermal fibroblasts that was comparable to natural collagens [241] . to further tune the gel properties, ichise et al. appended multiple end-to-end disulfides through crosslinking of chemically synthesized triple-helical clp. rheology showed that gel stiffness is controlled by the number of cysteine residues up to three, at which point it plateaus. with the incorporation of an integrin α 2 β 1 -binding sequence, the peptide polymer showed receptorspecific cell binding in vitro. moreover, cell signaling activity and biodegradability of such a system can be tuned by altering the content of integrin binding ligand in the peptide polymer and by varying the weight percentage of clp [242] . π-π interaction in clp self-assembly: the maryanoff group introduced an aromatic-aromatic recognition motif at either the n-or c-terminus of each peptide chain of the clp triple helix to drive the supramolecular assembly of clps [243, 244] . the aromatic π-π interaction facilitated head-to-tail stacking of clps into a micrometer-sized fibrillar structure, as evidenced by cd, 1 h nmr, dynamic light scattering (dls), tem, afm, and computational energy dynamics. the fibrillar clps induced the aggregation of human blood platelets, an ability lacking in less organized clps, with nearly the same potency as native type i collagen [245] . kar et al. investigated how the presence of aromatic residues on neither end, one end, or both ends of a collagen model peptide affected the kinetics of self-association. clps with aromatic residues at both termini self-assembled and aggregated too quickly to be monitored by turbidimetry at a concentration of 7 mg/ml [246] . similar interactions, such as ch-π interaction between amino acids (proline and hydroxyproline) and aromatic residues (phenylalanine and tyrosine) and cation-π interaction between a positively charged n-terminal arginine and a c-terminal phenylalanine, were also introduced to fabricate collagen-like fibrillar structures in a head-to-tail manner [246, 247] . hydrophobic interaction in clp self-assembly: hydrophobic interactions also contribute to clphybrid self-assembly and collagen-mimicking properties. the field and tirrell research groups independently synthesized clp-hybrids by conjugating collagen peptides with single or double hydrocarbon tails. lipidation of clps increased the triple helix stability, triggered self-assembly of the clp-hybrid in spherical micelles, induced the formation of lipid film, and promoted cell adhesion [248, 249] . to induce even higher-order assembly, the tong research group designed a series of clps consisting of four segments: an n-terminal palmitoyl segment, a β-sheetforming domain, a polylysine spacer, and a bioactive clp domain [250] . a clp with the sequence (gpo) 3 gfoger(gpo) 3 and a c-terminal c 16 hydrocarbon tail self-assembled into micrometer-long fibers with a 16 nm diameter in aqueous solution. self-assembled peptide nanofibers made of triple-helical clp constructs with bioactive gfoger sequences recognized and adhered to several integrin receptors and promoted cell spreading, thereby mimicking native collagen [250] . electrostatic interaction in clp self-assembly: the conticello and chaikof research groups first presented evidence of a self-assembled, fibrous, collagen-like structure with a well-defined dperiodicity using lateral electrostatic interaction through a sticky-ended nucleation strategy, j o u r n a l p r e -p r o o f reminiscent of that commonly used in the assembly of dna [251] . they used a synthetic peptide sequence (prg) 4 (pog) 4 (eog) 4 consisting of three distinct segments: a central tetrameric pog sequence flanked by an arginine-containing positively charged domain at the n-terminus and a glutamic acid-containing negatively charged domain at the c-terminus (figure 13 ). tem suggested that in the absence of thermal annealing, non-banded fibers are formed. in contrast, fiber growth was observed within several hours after thermal annealing. a nucleation-growth mechanism was followed by the self-association of multiple triple helices, which was driven by electrostatic interactions between oppositely charged terminal residues and hydrophobic interactions between central domains from neighboring triple helices. building upon this concept, o'leary et al. proposed a new sequence (pkg) 4 (pog) 4 (dog) 4 by replacing arginine and glutamic acid with lysine and aspartic acid, respectively [252] . they argued that arginine has a higher propensity to hydrogen bond with a carbonyl group of a neighboring strand compared to lysine, which inhibits its ability to form a salt bridge with the carboxylate group of the glutamic acid and thus forms homogenous collagen mimetic nanofibers. the modified peptide sequence formed both homogeneous fibers and hydrogels, and the hydrogel was degraded by collagenase at a rate similar to that for natural collagen. raines's group adapted this approach to generate extended fibers a few microns in length with a highly symmetrical and uniform -tesselated‖ geometry that was dictated by the precise placement of lysine-aspartate salt bridges in the staggered triple helix building blocks. the extended geometry of this construct maximizes the surface area available to support the growth and maturation of cells [253] . notably, the banding periodicity of these peptide fibers (18 nm) is significantly longer than the length of the peptide itself (10 nm) [251] . this elongation suggests that the units driving self-assembly are not the individual triple-helical peptides but oligomers of multiple triple helices that are preorganized such that their assembly into mature fibers leads to periodic packing and charge distribution, as visualized by tem. this contrasts with the native type i collagen fiber, in which staggered assembly of individual collagen molecules is responsible for the periodic banding pattern and suggests that true mimicry of the natural collagen assembly process has yet to be achieved. hydroxyproline (o-propionate hydroxyproline, p e ) that shows ph-sensitive folding [254] . melting and folding experiments using cd indicated that introducing 1-3 units of the unnatural amino acid p e into the backbone had little effect on triple helix stability at acidic and neutral ph, although the rate of folding into the triple helical structures were different. they also observed that a peptide in which all seven hydroxyproline residues were substituted with p e underwent ph-triggered folding with an even lower transition temperature than the parent clps [254] . research group led by chmielewski and hsu also placed metal-binding ligands at various points along the clp backbone for chelation-controlled higher-order assembly. they appended histidine or iminodiacetic acid to the termini of the (pog)n backbone and upon adding divalent metal ions, such as ni 2+ , zn 2+ , and cu 2+ , the clps co-assembled into petal-like microstructures with a periodic banding at the nanometer scale [255] . subsequent work from the chmielewski group demonstrated that a diverse range of distinct structures, including microflorettes, stacked sheet microsaddles, and fiber-like meshes, could be made by varying the length of the (pog)n core of the peptides and the metal ion concentration. [256] . as demonstrated by hsu and coworkers, a similar metal-promoted supramolecular assembly can also be obtained by introducing histidine residues at both termini as well as into a clp backbone lacking hydroxyproline. a variety of higher-order structures were obtained, ranging from the nano-to micro-scale [219] . metal-induced self-assembly is advantageous over lateral electrostatic interaction because diverse supramolecular structures can be obtained under mild physiological conditions. a repertoire of unsatisfied metal-ligand interactions are also available in these selfassembled structures that enable incorporation of functional peptide sequences [257] [258] [259] [260] for biomedical applications, including 3d culture of human endothelial cells, protein purification, and fluorescence tagging. temperature -triggered self-assembly of clps: kiick and co-workers recently reported the temperature -triggered self-assembly of clp-hybrid materials [261] [262] [263] [264] . they appended a synthetic polymer, poly(diethylene glycol methyl ether methacrylate) (pdegmema) or human tropoelastin -derived elastin-like polypeptide (elp, to be discussed in a later section) with clps. both pdegmema and elps are thermally responsive and exhibit lower lcst-phase behavior. above a transition temperature (t t ), they undergo reversible phase transition from a soluble phase to an insoluble coacervate, which drives the self-assembly of the clp-hybrid into vesicular-or platelet -like structures. conversely, triple helix formation of the clp chains drives the formation of a bilayer of the supramolecular assembly (figure 14 ) [265, 266] . it is important to note that the t t of the short elp sequence is drastically reduced in the clp-elp hybrid due to formation of a clp-triple helix that increases the local concentration of the elp. above the j o u r n a l p r e -p r o o f melting temperature of the clps, these nanostructures disassemble into unimers. moreover, the clp-elp vesicle can target type ii collagen, which is overexpressed in various diseases, including cancer, through triple helix hybridization. these vesicles exhibited sustained release of an encapsulated fluorophore over a period of three weeks, and complete release was triggered by destroying the clp -helical structure with heat [267] . gelatin is a well-known, biodegradable, biocompatible, and nonimmunogenic biomaterial obtained either by partial acid or alkaline hydrolysis or by thermal or enzymatic degradation of type 1 collagen [268] . gelatin is composed primarily (85-92%) of proteins, with minerals and water constituting the rest. gelatin is used in a wide range of food, cosmetic, and pharmaceutical applications [268, 269] . the triple helix conformation of gelatin endows it with high thermal stability in solution [270] . the use of gelatin has gained popularity for the following reasons: (i) gelatin is readily available and inexpensive; (ii) gelatin is highly soluble and easy to use; (iii) gelatin's structure is highly similar to that of collagen and contains peptide binding motifs for cell attachment; (iv) gelatin is biocompatible, biodegradable, and does not induce antigenicity or at the sequence level, gelatin molecules contain repeating (gly-x-pro)n triplets, where x represents the amino acid (usually lysine, arginine, methionine, or valine), that is responsible for the triple helical structure of gelatin. gelatin is a polyampholyte that is ~13% positively charged (lysine and arginine), ~12% negatively charged (glutamic and aspartic acid), and ~11% hydrophobic (leucine, isoleucine, methionine and valine) [271] . another important trait shared by collagen and gelatin is the low frequency of aromatic amino acids -tryptophan, tyrosine, and phenylalanine-in their primary sequence. the low frequency of these amino acids is the primary reason for the low antigenicity and toxicity of both gelatin and native collagen [272] . commercially, two different types of natural gelatin -cationic type a & anionic type b-are j o u r n a l p r e -p r o o f available and differ based on the details of the manufacturing process -collagen hydrolysisused to obtain them [273] . gelatin a is obtained from porcine skin following acid pre-treatment, which minimally hydrolyses the amide groups of glutamine and asparagine and results in a macromolecule with a pi ranging from 7 to 9. conversely, gelatin b is extracted from osseincut bovine hide-and is pre-treated at alkaline conditions, which leads to hydrolysis of asparagine and glutamine to aspartate and glutamate, respectively, thus resulting in a lower pi of 4-6. recombinant gelatin, which can serve as a substitute for the natural protein, is also commercially available [274, 275] . however, unlike collagen, gelatin suffers from mechanical instability and has high rate of degradation. it is also highly susceptible to several proteases. gelatin nanoparticles (gnps) prepared without crosslinking were unstable and formed aggregates [271, 273] . for these reasons, crosslinking of gelatin-based materials is required to give it mechanical stability, shape, and enhanced circulation time in vivo [8, 271, 276] . crosslinking of gelatin can improve its thermal and mechanical stability, as well as lower its degradation in vivo. crosslinking, which modifies cleavage sites of gelatin molecules, inhibits enzyme-substrate interactions and hence increases the resistance to degradation [277] . various crosslinking agents, including aldehydes, genipin, carbodiimide/n-hydroxysuccinimide, and enzymes, have been explored to covalently crosslink gelatin [268, 271] . the crosslinking density, defined as bloom number, of the gelatin biomaterials can be altered by the crosslinking reaction conditions and/or increasing the concentration of crosslinker, thus regulating its physicochemical and biomedical properties. in addition, the mechanical properties of gelatin can also be tuned by temperature and ph. at a sufficiently high concentration, gelatin forms a semisolid hydrogel at lower temperatures. as the gelatin solution cools to below 30°c, a random coil to triple helix transition, promoted by stable hydrogen bond formation, occurs [278] . changes in ph affect the melting temperature of gelatin and hence the propensity for gel formation. moreover, changes in ph modify ionic interactions between gelatin monomers and consequently affect hydrogen bondmediated crosslinking [279] . physical crosslinking is also possible and can reversibly modulate gel strength and has the advantage that it does not need enzymes or chemical reagents to effect crosslinking [280] . various methods such as desolvation, coacervation, emulsification, nanoprecipitation, and layer-by-layer coating have also been used to fabricate gelatin-based systems for drug and gene delivery [268, 271] . gelatin nanoparticles (gnps) range from 200 to 400 nm in size [281] . colloidal stability, drug release, drug encapsulation, tissue distribution, and cellular uptake are strongly dictated by the charge and size of gnps. the effects of various parameters, such as temperature, ph, j o u r n a l p r e -p r o o f cosolvents, degree of crosslinking, and type of gelatin, on the physicochemical properties of gnps have been investigated by several groups [282] [283] [284] . a temperature of 40°c was found to be optimal to attain a narrow size distribution of gnps because at q high temperature (50 °c), gelatin forms a random coil, which destroys the self-assembly and the nanoparticle while at room temperature, gelatin forms a highly viscous semi-solid. in contrast, at 40 °c, a controlled uncoiling of the triple-helical structure results in monodisperse gnps. the size and dispersity of gnps is highly dependent on solution ph, and ph 3 and ph 11 were found to be optimal for nanoparticle formation of cationic type a and anionic type b gelatins, respectively. increasing the degree of crosslinking results in greater polydispersity and a reduction in particle size. gnps and their hybrids have been explored to encapsulate both hydrophobic and hydrophilic bioactive molecules including antimalarial drugs [285] , such as chloroquine phosphate; anti-cancer drugs [271, 286] , such as paclitaxel, dox, cisplatin, curcumin, and methotrexate; growth factors [287] , such as osteogenic bone morphogenetic protein-2 (bmp-2), and angiogenic basic fibroblast growth factor (bfgf); anti-inflammatory drugs [288] , such as ibuprofen; photo-responsive dyes [289, 290] ; anti-hiv drugs [291] such as didanosine; and therapeutic nucleic acids [271, 292] . in all cases, an on-demand release profile was achieved by controlling the degree of crosslinking, ph, temperature, and fabrication method and thus the physicochemical properties of the gnps. for example, amjadi et al. designed a ph-responsive nanocarrier by decorating the gnps with (methoxy poly (ethylene glycol)-poly ((2dimethylamino) ethyl methacrylate-co-itaconic acid) (pgnps) (figure 15a ) [286] . the nanoparticles (162 nm diameter) were encapsulated with dox and betanin with high efficiency (loading capacities of 20.5% and 16.25%, respectively), and demonstrated ph-and temperature -responsive drug release, and synergistically inhibited the growth of mcf-7 breast cancer cell lines. in another example, rose bengal -conjugated gelatin nanoparticles (rb-gnps) were developed for antimicrobial photodynamic therapy ( figure 15b ) [290] . rb-gnps generated singlet oxygen that damaged the microbial cell membrane, which demonstrated their potential for treating multi-drug-resistant microbial infections. gelatin microparticles (gmps) have been extensively investigated for many biomedical applications. solorio et al. engineered self-assembled, gelatin microsphere-incorporated human mesenchymal stem cell (hmsc) sheets [293] . the microspheres were loaded with growth factor tgf-β1, distributed within the hmsc sheets, and released chondrogenic growth factor to the j o u r n a l p r e -p r o o f interior of the sheets, thus enabling spatially homogenous differentiation of the hmscs. the differentiation rate could be tailored by adjusting the microsphere crosslinking levels, which controls the release kinetics of the growth factor. this system not only produces hmsc sheets with superior mechanical properties but also decreases the pre-implantation culture time. in addition, the hmscs are continuously exposed to growth factor by microparticles, which prevents loss of the chondrogenic phenotype in vivo. similar controlled release of growth factor and proteins from gmps to stimulate tissue regeneration have been achieved for vascular endothelial growth factor (vegf) [294] , bone morphogenetic protein-2 (bmp-2) [295] , basic fibroblast growth factor (bfgf) [296] , and matrix metalloproteinases (mmps) [297] . in all cases, the release kinetics were dependent on the degree of crosslinking of gmps. it is well known that the use of most hydrophobic drugs is limited by their poor aqueous solubility, short circulation time, low bioavailability, and narrow therapeutic window. gmps have been used to address some of these challenges. for instance, the antibacterial activity of curcumin -a hydrophobic polyphenol derived from turmeric with a wide range of biological properties-is negligible at concentrations up to 100 mg/ml. however, curcumin encapsulated in gmps at 4 mg/ml reduced the microbial population by 2.08, 1.67, 2.70, and 2.18 log counts (cfu/ml) for l. monocytogenes, s. enterica, s. aureus, and e. coli, respectively [298] . gmps encapsulated with noscapine, an anticancer drug that targets human nsclc, demonstrated first order release kinetics and increased the plasma half-life of the drug by ~ 10-fold with an accumulation of ~50% drug in the lungs [299] . kim et al. used a microfluidic approach to fabricate monodisperse gmps with a microshell structure for embolization, a minimally invasive, nonsurgical procedure that deliberately blocks a blood vessel [300] . uniform gelatin emulsion precursors were fabricated using the microfluidic technique and consecutively crosslinked by inbound diffusion of glutaraldehyde from the oil phase to the suspending droplets of gelatin precursor. the authors also performed a model micromechanics study in an artificial blood vessel, which revealed that the microshell structure results intorapid degradation of the gmps within a narrow time period leading to burst release of the drug under chemoembolic conditions. gelatin fibers are used for various biomedical applications such as tissue-engineering and wound-healing, due to their morphological resemblance to the structure of the native ecm. gelatin fibers can be fabricated by several methods, such as melt spinning, wet spinning, gel spinning, electrospinning, centrifugal spinning, and solution/melt blow spinning. multiple processing parameters, including solution properties, humidity, and temperature, can influence the morphology of nanofibers and release rate of the entrapped drug. for instance, nanofibers fabricated by electrospinning of poly (d, l-lactide-co-glycolide) (plga) and gelatin were loaded with fenbufen. the hydrophilicity of the fibers was enhanced by increasing the gelatin content, which in turn increased the release rate of fenbufen. in contrast, the addition of a crosslinker (glutaraldehyde vapor) reduced the drug release rate [41] . vitamins a and e incorporated in gelatin nanofibers via electrospinning promoted the proliferation of fibroblasts, increased the expression of collagen-specific genes, and supported wound healing [301] . another research group demonstrated that genipin-crosslinked gelatin fibers loaded with human vegf sustained viability, promoted endothelial differentiation, attracted human mesenchymal stem cells (hmscs) and stimulated early angiogenesis [302] . chemically modified gelatin has been extensively used as hydrogel because of its tunable mechanical and biochemical properties. gelatin-methacryloyl (gelma), a synthetic, photosensitive crosslinkable derivative of gelatin, is widely used as a precursor to fabricate gelatin hydrogels and is commercially available as a bio-ink for 3d printing. various crosslinking methods, such as ultraviolet stereolithography, gamma irradiation, and two-photon polymerization, have been used to fabricate gelatin-based hydrogel and scaffolds [303] . light-activated crosslinking of methacrylated gelatin in air or in an aqueous solution resulted in an injectable hydrogel that supported hmsc growth and tgf-b3-induced chondrogenesis [304] . mazaki et al. developed furfurylamine-conjugated gelatin (gelatin-fa) that was rapidly crosslinked by visible light with rose bengal [305] . hybrid gelatin hydrogels can also be made from various synthetic polymers, including plga, poly (hydroxyethyl methacrylate), and polyvinyl alcohol, or natural polymers, such as chitosan and alginate. composite hydrogels consisting of gelatin, polyvinyl alcohol, and the anticancer drug cisplatin were synthesized as a controlledrelease drug delivery system. in vivo, inhibition of tumor growth was similar for hydrogels containing a low dose of cisplatin and conventional intraperitoneal administration of high doses of free cisplatin [306] . kinsella and colleague fabricated various alginate-gelatin bio-printable composite hydrogels that resemble the microscopic architecture of native tumor stroma [307] [308] [309] . 3d-printed hydrogels embedded with breast cancer cells, and fibroblasts promoted the self-assembly of breast cancer cells into multicellular tumor spheroids (mcts), which were viable for more than 30 days [307] . gelatin -based tissue bioadhesives, fabricated alone or with other synthetic and natural polymers, have also been used in drug delivery. composite tissue adhesives, developed by carbodiimide -mediated crosslinking of gelatin and alginate, were used to entrap the antiinflammatory drugs bupivacaine and ibuprofen, and the resulting adhesive was used for local pain management [310, 311] . hydrophilicity of the adhesive and its swelling properties control the release of drugs from this matrix. the incorporation of a drug -bupivacaineimproved the bonding strength of the adhesive, whereas incorporation of ibuprofen adversely affected the bonding strength. this is due to the inert nature of bupivacaine and the reinforcing effect of its fibrous crystals. in contrast, ibuprofen reacts with the crosslinking reagent -carbodiimideand decreases the crosslinking density and hence bonding strength of the adhesive networks [311] . to address this issue, n-hydroxysuccinimide can be added during crosslinking of gelatin and alginate to decrease the carbodiimide content without compromising the bonding strength. the resulting patch is less cytotoxic (due to low carbodiimide content) and can be used for controlled release of various antibiotics such as clindamycin, vancomycin, and ofloxacin [310] . like collagen, elastin is a key protein found in the ecm and connective tissues. it is abundant in organs that require elasticity and resilience for their function, including skin, ligaments, lungs, and blood vessels [312] . its inherently disordered structure provides elastin with unique properties that impact its recombinant production and purification, drug-loading capacity, and in vivo behavior. the soluble precursor to elastin, tropoelastin, is composed of alternating hydrophobic and hydrophilic domains that undergo enzymatic crosslinking via their lysine residues in the extracellular space. the resulting elastin fibrils are durable and insoluble. although these characteristics are critical for its function in biological tissue, they were a hindrance during early efforts to manipulate elastin as a biomaterial [313] . consequently, soluble and recombinant forms of elastin were explored. the most widely studied elastin-based materials used for drug delivery are elastin-like polypeptides (elps) [314] . elps are biopolymers with the val-pro-gly-x-gly pentapeptide motif, in which x represents any amino acid besides proline [315] . perhaps the most interesting property of elps is their thermal responsiveness, as they demonstrate lcst phase behavior. in an aqueous solution, they are soluble below a characteristic transition temperature (t t ). above their t t , elps reversibly phase transition and forms an insoluble, polymer-rich phase. this behavior is thermodynamically driven by the j o u r n a l p r e -p r o o f favorable entropy of demixing above the t t (figure 16a & b) [316] . spontaneous mixing occurs when the gibbs free energy change is negative. for an elp to be solubilized, water molecules must be ordered along the polypeptide chain. this interaction results in a negative entropy term. a small temperature term compensates for this hit in entropy, which keeps the gibbs free energy change negative and allows the elp to stay in solution. however, as the temperature term increases, elp-water mixing becomes more energetically unfavorable. the entropy term becomes dominant, causing the elp to aggregate into a -coacervate‖ phase. the temperature at which this phenomenon occurs is dependent on multiple features of the elp and the solution environment [317, 318] the elp's molecular weight and concentration in the aqueous solution are inversely related to its t t , which is also impacted by the guest residue. high concentrations of hydrophobic residues, such as lysine or valine, depress the t t and high concentrations of hydrophilic residues, such as alanine or glycine, increase the t t [319] . elps retain their lcst behavior when recombinantly fused to a drug, targeting moiety, or other molecule, but the t t can be similarly affected by the surface hydrophobicity and charge of its fusion partner [320] . the t t of an elp solution can be easily quantified by optical turbidity measurements of an elp solution at 350 nm (od 350 ) as a function of solution temperature. as the temperature is increased, the elp will transition from an optically transparent solution to an opaque mixture within a narrow, 1-2°c temperature window. the t t can be graphically determined at the inflection point of an od 350 vs temperature plot, which is typically a sigmoidal curve (figure 16c ) [321] . because the t t is concentration dependent, it should be analyzed over a range of application -relevant concentrations. the lcst behavior of elps can also be used in a chromatography-free purification process termed inverse transition cycling (itc). initially developed by meyer and chilkoti, this procedure cycles cell lysate through a series of hot and cold centrifugation steps [322] . after insoluble cell debris is removed from the lysate via centrifugation, the elp-containing supernatant is heated above the t t of the elp. kosmotropic salts, which interact more favorably with the water along the elp chain, may be added to facilitate the phase transition and promote aggregation. the solution is centrifuged to pellet the elp while soluble contaminants remain in the supernatant. the elp pellet is then dissolved in cold buffer and centrifuged below the t t , which causes insoluble contaminants to precipitate while the elp remains in solution. this process is rapid and inexpensive, avoids the use of harsh chemicals, and can be scaled up [322] . elps have hence been used as a purification tag for other proteins [323] . after itc, the elp can be cleaved from the protein of interest using a proteolytic cleavage site or self-cleaving intein that is incorporated between the elp and protein [324, 325] . j o u r n a l p r e -p r o o f though small molecule drugs and peptides demonstrate potency and -in the case of peptides-specificity, their efficacy is frequently hindered by their rapid clearance from circulation or poor solubility (kalepu & nekkanti, 2015) , necessitating frequent dosing [326, 327] . [328] scientists have addressed these limitations by conjugating macromolecular carriers to these therapeutics to improve their circulation time, target-site accumulation, and solubility [327, 329] . soluble elp unimers have been recombinantly fused to therapeutic peptides and chemically conjugated to small molecule drugs for these purposes [330] [331] [332] . elp fusions benefit from the large molecular weight of the elp, which extends the circulation time of the fusion partner, and enhance the solubility of the drug, and improve their biodistribution, and pharmacokinetic profiles. compared to synthetic drug carriers, elps benefit from monodispersity and a lack of toxicity [315] . despite the advantages of employing elps as soluble macromolecular carriers, they lack the stealth properties provided by some hydrophilic polymers, such as poly(ethylene glycol) and zwitterionic polymers [333] . these -stealth‖ polymers create a hydration sphere around the payload and polymers, which improves the pharmacokinetic profile of the conjugate by protecting it from opsonization and premature clearance from circulation [334] . recently, banskota and coworkers modified the canonical elp sequence to impart stealth behavior to biopolymers [335] . they designed zwitterionic polypeptides (zipps), which are composed of repeat units of the val-pro-x1-x2-gly motif, where x1 and x2 are positively and negatively charged amino acids, respectively ( figure 17a) . like elps, zipps can be recombinantly expressed in e. coli, and exhibit the favorable properties of elps including monodispersity, ability to recombinantly be fused to a therapeutic peptide, and sequence-level control of their properties. additionally, zipps can be purified without chromatography by inverse transition cycling, similar to elps. zipps provide greater solubility to their payload than elps as a result of their charged residues [335] . most importantly, zipps had a 3-fold longer half-life and 2-3-fold greater bioavailability compared to an uncharged elp control. consequently, when glp-1 was j o u r n a l p r e -p r o o f fused to either a zipp or a mw-matched uncharged elp control, the zipp achieved 1.5-fold longer blood glucose control, which demonstrates that the stealth behavior of zipps can increase the efficacy of their therapeutic cargo (figure 17b ) [335] . owing to their ease of production and thermal phase behavior, elps are useful materials for design of self-assembling nanostructures and nanoparticles to deliver a variety of therapeutic agents. elp nanoparticle self-assembly is driven by hydrophobic interactions. depending on the design, the hydrophobic component might be either an elp segment or its conjugated hydrophobic cargo. elp amphiphiles, which contain two connected elp blocks with different hydrophobicities and hence t t , form micelles at temperatures between the t t of each block. at phenylalanine and valine were the guest residues. due to the presence of ionizable residues in the sequence, the size and shape of the self-assembled nanoparticles were ph-sensitive. above the cmt, these elp fusions self-assembled into spherical and cylindrical morphologies [336, 337] . conticello et al. later designed triblock elps, which were made of a hydrophilic block between hydrophobic end blocks [338] . the hydrophobic blocks phase transitioned and aggregated to act as -crosslinks‖ in an elastomeric network. j o u r n a l p r e -p r o o f subsequently dreher and coworkers systematically explored the design parameters that controlled elp nanoparticle self-assembly by creating a library of ten diblock elps [339] . they discovered that the temperature at which unimers assemble into micelles depends upon the length of the hydrophobic domain. in contrast, micelle diameter is controlled by the length of the copolymer and the ratio of hydrophobic to hydrophilic blocks. dreher et al. also incorporated a functional ligandthe tumor-homing ngr peptide sequence at the terminus of the hydrophilic segment of a diblock elp. these micelles were readily internalized by cells that recognized the displayed ligand, which demonstrates that the elp diblock design can be engineered for targeted drug delivery [339] . several models have contributed to our understanding of diblock elp self-assembly. elps based on the t t values of each elp domain. they found that although the cmt was dependent on the hydrophobic domain, the bulk transition temperature was dependent on the hydrophilic block [340] . a second, theoretical model developed by hassouneh et al. used polymer physics to study micelle assembly. upon examination of six diblock elps, they found that these copolymers form -weak‖ micelles with dense cores and unstretched coronas, which is unique for diblock polymer micelles [341] . the initial studies on diblock elp micelle targeting were expanded by the development of dynamic affinity modulation, a strategy in which local hyperthermia induces micelle formation to increase the avidity of a low-affinity ligand that is fused to the n-terminal end of the hydrophilic segment of diblock elp for site-specific accumulation and targeting. simnick and coworkers first used this strategy in a proof -of -concept study in which a low-affinity ligand specific to α v β 3 integrin was recombinantly fused to the n-terminus of an elp [342] . cysteine residues were incorporated at the c-terminus for drug conjugation. at temperatures below the cmt of the elp, the fusion protein existed as a soluble unimer and the low-affinity ligand interacted weakly with the α v β 3 integrin. in the presence of local hyperthermia, the elp underwent temperature -triggered self-assembly into spherical micelles, thus increasing the valency and avidity of the ligand such that it could efficiently bind to and be taken up by cells [342] . this strategy was then modulated to achieve more specific cell internalization of cell-penetrating peptides (cpps) [343] . cpps are arginine -rich sequences that promote uptake by electrostatically interacting with the cell membrane of multiple cell types. cpps have been conjugated to nanoparticle surfaces to improve their internalization but lack specificity. macewan and chilkoti addressed this issue by incorporating five arginine residues onto a diblock elp. they found that below the cmt, the number of arginine residues was below the threshold of six necessary to induce cell uptake [344] . local hyperthermia drove the formation of micelles that displayed a high valency of arginine on their surfaces, resulting in 8-fold increase in cell internalization [343] . the design of these nanoparticles and their thermal -switch‖ allow for control over the site of action of elp nanoparticles, which can reduce off-target drug delivery and mitigate systemic toxicity. furthermore, adding these targeting moieties did not disturb micelle formation. hassouneh and coworkers showed that when proteins ~10 kda in size are incorporated at the end of the hydrophilic block, the diblocks still self-assembled [345] . diblock elps have also been designed for applications beyond cancer, including specific targeting to liver cells [346] and lacrimal gland cells [347] . to improve tumor-specific drug delivery of diblock elp micelles, callahan and coworkers engineered a diblock elp that disassembled in the acidic tumor microenvironment [348] . histidine, which has a pka near physiological ph, was incorporated into the hydrophobic block. these micelles assembled at 37°c, but upon exposure to the low ph conditions mimicking the tumor microenvironment (ph ~6), the histidine became ionized. consequently, the t t of the hydrophobic block increased, and it was no longer energetically favorable for elps to selfassemble. the micelles broke down into elp unimers, resulting in better penetration and accumulation of the elp in the tumor compared to ph insensitive elp micelles. this study demonstrated that diblock elps can be engineered to overcome the diffusion barrier many nanocarriers face when delivering drugs to tumors [348] . mackay and coworkers have adapted diblock elps nanoparticles for two-phase rapamycin release by nonspecifically entrapping the drug in the nanoparticle core as well as specifically displaying the drug on the nanoparticle corona [349, 350] . this type of display was achieved by appending fk506 binding protein12 (fkbp12), the cognate protein target of rapamycin, to the hydrophilic block of the elp fusion. the entrapped rapamycin was rapidly released upon administration, while the release of fkbp12-bound rapamycin was prolonged. the two-phase release increased the terminal t1/2 of rapamycin to 57.8 h compared to 2.2 h for nanoparticles without fkbp12-bound rapamycin [350] . the nanoparticle formulation also reduced off-target toxicity compared to the free drug. in the aggressive breast cancer model mda-mb-468, treatment with the nanoparticle resulted in more potent reduction in tumor volume and extended survival time [350] . in a model for the chronic autoimmune disease sjögren's syndrome, the treatment downregulated inflammation in the endocrine gland and reduced lymphocytic infiltration into the lacrimal gland [349] . other elp nanoparticle designs fuse an elp segment with a peptide or protein to drive self-assembly. in an early example of this method, mcdaniel and coworkers incorporated repeats of the sequence (xg y ) z onto the elp c-terminus, where x is a hydrophobic residue [351] . relative to the elp, the (xg y ) z domain is only a few percent by mass in the diblock. despite the low mass fraction of the second segment, it was surprising and notable that these highly asymmetric amphiphiles self-assembled into cylindrical micelles with lengths that could be controlled by altering the identity of x or the value of y-the number of glycine spacers [351] . mackay et al. further explored how small proteins and peptides impact nanoparticle assembly. they discovered that fusing an scfv -a single chain antibody-to a hydrophilic elp block drives the fusion to self-assembly into a worm-like micelle, with the elp forming the corona [352] . despite being entrapped in the core, the scfv remained active due to the low packing density of the corona. these nanoworms outperformed their antibody equivalent in an in vivo xenograft model of lymphoma [352] . another study by mckay and coworkers was driven by the amphipathic nature of l4f, whose four phenylalanine residues orient face-to-face to create vesicles with 8 nm thick lamellae and a 49 nm radius [353] . l4f maintained its anti-inflammatory properties despite being in the vesicle lamellae. this study demonstrates how amphipathic peptides may be used to drive elp vesicle formation, which can be leveraged to encapsulate soluble therapeutics into the aqueous vesicle interior. hydrophobic drug conjugation can also trigger elp self-assembly into nanoparticles, masking the drug inside the core, thus increasing the aqueous solubility of the drug and protecting it from premature release and degradation. this results in improved drug half-life, biodistribution, tumor accumulation, and efficacy while reducing off-target toxicity. an early example of this strategy was developed by chilkoti and coworkers. in their bottom-up nanofabrication method, termed attachment directed assembly of micelles (adam), a hydrophobic (cgg) 8 domain was conjugated to the c terminus of a hydrophobic elp [354] to create a -chimeric polypeptide‖ (cp). the cysteine-rich domain of the cp enabled the attachment of up to eight maleimide -functionalized small molecules (figure 18) . when the hydrophobicity of the small molecule exceeds a threshold (log ≥ ~1.5), it provides the conjugate sufficient amphiphilicity to drive self-assembly [354] . this platform was adapted for drug delivery by chemical conjugation with dox to create cp-dox nanoparticles, which self-assemble at physiological ph at concentrations above 3 µm. dox is rapidly released upon exposure to an acidic ph (5) , which mimics the conditions of late endosomes and lysosomes. a single injection of cp-dox had 4-fold higher maximum tolerated dose and reduced tumor size nearly 13-fold compared to free drug, indicating that this nanoparticle formulation can be harnessed to j o u r n a l p r e -p r o o f enhance potency while reducing off-target effects such as cardiotoxicity. adam has also been leveraged to deliver the hydrophobic chemotherapeutics paclitaxel [355] and niclosamide [356] . while the original adam strategy was successful at enhancing the efficacy and safety of hydrophobic chemotherapeutics, many cancer drugs are hydrophilic and cannot be encapsulated by this strategy. to address this, the chilkoti and coworkers developed a new strategy by the design of an asymmetric triblock polypeptides [357] . atbps consist of three segments-a hydrophilic elp segment that is fused to a hydrophobic elps segment that in turn is fused to a drug attachment (ggc)8 segment. the atbp is deigned to retain its temperature triggered amphiphilicity even upon conjugation of hydrophilic small molecules with a logd ≤ 1.0 that the drug-conjugated atbp self-assembles into rod-shaped micelles above its cmt, which is designed to be below body temperature. they showed that conjugation of hydrophilic drugs, such as gemcitabine, to the cysteine residues of the atbp did not abrogate the formation of micelles, and these drug-loaded atbp micelles had greater efficacy in an aggressive in vivo model of colon cancer compared to free drug [357] . while cysteine-maleimide covalent conjugation can incorporate a structurally diverse set of drugs, molecules, and imaging agents into the nanoparticle's core, this strategy relies on functionalization of a naturally occurring amino acid. these residues can be promiscuously distributed across other peptides that may be appended to the elp such as targeting peptides or proteins, and, consequently, site-specific drug attachment for these constructs is challenging. to address this concern, costa and coworkers inserted p-acetylphenylalanine, an unnatural amino acid, onto an elp micelles that displayed a functional nanobody [358] . the nanobody contains a disulfide bond that is essential for its stability and functionality, so that site specific covalent conjugation of a drug by introduction of cysteine residues in a drug attachment was not possible. the p-acetylphenylalanine residue provided a biorthogonal ketone moiety to sitespecifically conjugate dox via a ph-sensitive bond without affecting the disulfide bond of the nanobody. as a result, this platform enabled site-specific drug conjugation while enabling the display of a functional nanobody on an elp nanoparticle [358] . [354] . fatty acids have also been incorporated by a post-translation modification into elps to drive nanoparticle assembly. luginbuhl and coworkers incorporated a myristoyl group at the nterminus of an elp that presented a peptide substrate for n-myristoyltransferase. the enzyme was co-expressed with the elp from a bicostronic plasmid in e. coli that grown with exogenous myristic acid added to the culture medium [359] . this led to close to 100% myristoylation of the elp in e. coli, and the myristoylated elp (m-elp) formed spherical or rod-like micelles depending on the elp chain length. chemotherapeutic drugs could be physically loaded into the micelles via hydrophobic interactions with the fatty acid, which resulted in a greater encapsulation efficiency than that possible with diblock elps [359] . this strategy thus provides a useful mechanism for entrapping drugs without covalent conjugation, making it possible to deliver drugs that do not contain an active functional group for conjugation, or drugs that lose potency upon conjugation. elps have been similarly combined with silk to form silk-elastin like protein (selp) nanoparticles [71, 360] . nanoparticle self-assembly is driven by both hydrophobic interactions and hydrogen bonding between the silk blocks. the radius of the nanoparticle is controlled by altering the elp guest residue as well as the ratio of silk blocks to elp blocks [361] . xia and coworkers demonstrated that these nanoparticles can be used to deliver hydrophobic small molecule drugs by loading dox into the nanoparticles [362] . dox was entrapped in the core by hydrophobic interactions with the silk blocks. the selp nanoparticles were endocytosed into the cell, thus allowing drug to accumulate in the cytoplasm. the cytotoxicity of the selp-dox nanoparticles was 1.8-fold greater than that of free dox [362] . elps provide a useful platform for sustained drug release due to their lcst behavior. their t t can be precisely tuned by modulating the molecular weight and guest residue of the sequence, making it possible to engineer the elp with a t t below physiological temperature. the elp thus remains soluble at room temperature, enabling injection through narrow-bore syringe, but rapidly coacervates upon exposure to body temperature, forming a subcutaneous depot. because the t t is concentration -dependent and the boundary layer of the coacervate is diluted by interstitial flow, the depot slowly undergoes surface-to-core dissolution. as it dissolves, the therapeutic cargo is released into circulation. this sustained -release platform, coupled with the ability of elps to impede renal filtration, extends the half-life of small molecules and peptides to which the elp is fused. prolonged -release systems are advantageous for diseases that require long-term treatment, such as cancer or chronic illnesses. liu et al. systematically altered elp parameters to adapt the molecule for in situ radiotherapy [363, 364] . they recombinantly fused a hydrophobic elp, comprised of 60 repeats of a val-pro-gly-val-gly pentapeptide, to a tyrosinerich domain that could be radiolabeled with 131 i. an intratumoral injection of the 131 i-elp was retained in the tumor for more than one week. the elp shielded the radionuclide from dehalogenase degradation and increased its tumor retention time [363] . liu and coworkers found that doubling the molecular weight of the elp increased tumor retention time by 14-fold; however, the effect plateaued with the t t once the elp surpassed 120 repeats. similarly, increasing the injection concentration of 131 i-elp 16-fold resulted in 5-fold greater tumor retention [364] . furthermore, 131 i-elps with seven repeats of the hydrophobic, tyrosine-rich peptide domain self-assembled into rod-shaped micelles and formed long-lasting -seeds‖. the seed-like particles exhibited potent anti-tumor efficacy, remarkable intratumoral retention, and minimal toxicity [364] . the coacervate was further stabilized by radiation-induced crosslinking of the tyrosine residues in the hydrogel, which resulted in retention of 52% and 70% of its radioactivity over 60 days in a prostate and pancreatic tumor model, respectively [365] . more recently, wang and coworkers engineered an elp depot for the sustained release of interferon-α, an anti-cancer protein that has been clinically hindered due to its short half-life and dose-dependent toxicity [366] . fusion of the protein to 90 repeats of a val-pro-gly-val-gly pentapeptide resulted in near zero-order release of ifn-α over the course of a month. compared to free ifn-α and ifn-α fused to a soluble elp, the depot-forming ifn-α-elp exhibited greater antitumor efficacy in a melanoma model. the fusion was well tolerated and demonstrated little renal toxicity, key advantages over free ifn-α [366] . the enhanced pharmacokinetics of glp1 are attributed to the increased residence time of depot-forming glp1-elp compared to the soluble control or glp1 alone. adapted with permission from [368] . elp depots have also been extensively engineered for the treatment of diabetes. antidiabetic peptides such as insulin and glucagon-like peptide-1 (glp-1) have short half-lives that necessitate frequent and repeated injections to achieve long-term blood glucose control. there is hence a need for sustained -release systems that prolong the efficacy of these peptides, and which reduce the need for multiple injections and improve patient compliance. glp-1 to and elp that was designed to coacervate at body temperature. the depots were retained in the subcutaneous space and lowered blood glucose levels for up to 5 days [367] . luginbuhl and coworkers expanded upon this work and optimized the elp parameters for depot retention and glp-1 half-life [368] . they discovered that elps with t t values of approximately 30°c and molecular weights greater than 36 kda achieved near zero-order release kinetics for glp-1. the optimized glp1-elp fusion formed a depot in the subcutaneous space upon injection as a solution and provided glycemic control in three different diabetic mouse models for up to 10 days after a single injection (figure 19) . in a cynomolgus monkey model, circulating levels of the elp fusion were detected for 17-21 days post-injection. glp-1 delivery has also been achieved by introducing protease cleavage sites between oligomeric repeats of glp-1 on an elp. once these so-called -protease-operated depots‖ are injected subcutaneously, proteases under the skin free glp-1 from the elp in the depot. this system extended blood glucose control for 5 days [367] . the antidiabetic protein fibroblast growth factor 21 (fgf21) has also been fused to an elp by gilroy et al. to improve its release, half-life, and production [369] . fusion to the elp enhances fgf21 solubility, thus allowing it to be expressed in the bacterial cytosol rather than inclusion bodies and consequently avoiding costly, complex refolding steps during purification. the elp-fgf21 depot was retained in the subcutaneous space for up to 4 days and achieved glycemic control in an ob/ob mouse model for up to 5 days. in a long-term study, treatment with an elp-fgf21 fusion resulted in 40% reduction in mean serum insulin and triglyceride levels when mice received subcutaneous injections every 5 days for up to 60 days [369] . other elp depots have been engineered for the treatment of dry eye disease [370] , infectious illnesses [371] , and inflammation [372] . resilin is another elastomeric protein that has been extensively engineered for biomedical applications. natural resilin is a rubbery protein with remarkable elasticity that is derived from the exoskeletons of insects and arthropods, where it is a critical component of locomotive systems such as jumping and flight [375] . it possesses high resilience and extensibility, low stiffness, and the ability to efficiently store energy [376] . these unique mechanical properties, coupled with its biodegradability, make resilin an attractive protein for regenerative medicine and drug delivery [377] . after ardell and anderson identified tentative resilin gene sequences in drosophila melanogaster [378] , elvin and coworkers engineered the first example of a recombinantly expressed resilin-like polypeptide (rlp) in 2005 [379] . the resulting polypeptide, termed rec1resilin, is composed of the first exon of the d. melanogaster cg15920 gene, which contains seventeen copies of the ggrpsdsygapgggn motif [379] . rec1-resilin possesses the favorable mechanical properties of native resilin with the added benefit of customizability provided by its recombinant synthesis. upon photochemical crosslinking of the tyrosine residues, rec1-resilin demonstrated up to 92% resilience that is comparable to that of many synthetic rubbers [379] . dros16. an16 is composed of sixteen repeats of an eleven amino acid motif found in anopheles gambiae while dros16 is composed of sixteen copies of a fifteen amino acid motif in the first j o u r n a l p r e -p r o o f exon of the cg15920 gene from which rec1-resilin is derived [380] . similar to rec1-resilin, these rlps were highly resilient, elastic, and capable of photo-crosslinking [380] . rlps are intrinsically disordered polypeptides that contain high concentrations of glycine, which provides them with high flexibility and makes secondary structure formation entropically unfavorable. the high proline content of rlps also prevents secondary structure formation, as the bulky residue reduces hydrogen bonding [381] . further, unlike other elastin-mimetic proteins, rlps contain high frequencies of polar and charged residues and are thus hydrophilic. rlps are responsive to a variety of stimuli, including temperature [382, 383] . rlps demonstrate dual phase behavior (dpb), an unusual property characterized by both a lcst and upper critical solution temperature (ucst), the temperature above which the rlp is fully miscible in solution. the dpb of rlps is fully reversible and largely dependent on the molecular composition and architecture of the rlp. their ucst behavior is also strongly impacted by ph [384] . at ph values greater than the pi, the charged residues enhance rlp solubility and the ucst increases. at low ph values, carboxylic acid residues on the rlp become protonated, which reduces the molecule's solubility and drives up the ucst [383, 385] . the tunable dpb of resilin is useful to fabricate modular drug delivery systems, described in the next section. the unique, temperature-driven phase behavior of rlps provides numerous opportunities for designing nanoparticles, whose size, shape, and aggregation number can be tuned to create drug delivery vehicles for a variety of applications. li et al. initially described the factors that impact rlp nanoparticle formation using a novel rlp based on twelve repeats of a fifteen amino acid consensus motif derived from d. melanogaster [385] . they replaced the tyrosine residues with phenylalanine and methionine, which can be leveraged for subsequent chemical modification. to form nanoparticles, the polypeptide was heated to its lcst of 65°c, at which point it irreversibly aggregated [385] . li and coworkers found that the lcst was concentration-and ph-dependent; transition temperature decreased with increasing concentration or decreasing ph (figure 20) . interestingly, the presence of salt improved rlp solubility and increased the transition temperature, which is the opposite of elps (figure 20) . this phenomenon is attributed to the ionizable residues in the rlp. the resulting nanoparticles can be tuned to have diameters ranging from 20 nm below the transition temperature up to nearly 400 nm when heated beyond their transition temperature [385] . this study demonstrates how the temperature-triggered phase behavior of rlps can be exploited to design nanoparticles with precision. block copolypeptides that incorporate rlps have also been used to create nanoparticles. the self-assembly of diblock copolymers containing both ucst and lcst blocks is strongly impacted by temperature. at low temperatures, the ucst block is relatively hydrophobic and aggregates at the core while the lcst block remains soluble. as the temperature increases, the ucst block becomes hydrophilic and relocates to the nanoparticle corona as the lcst block aggregates [386] [387] [388] . this phenomenon motivated weitzhandler et al. to combine rlps with elps to better characterize temperature-triggered phase behavior of ucst-lcst block co-polypeptides with the goal of nanoparticle formation [389] . using an rlp composed of repeat units of the gln-tyr-pro-ser-asp-gly-arg-gly octapeptide and an elp, they identified two principles that affect nanoparticle formationthe rlp:elp mass ratio and elp hydrophilicity. with an increase in the rlp:elp ratio, they observed an increase in the nanoparticle size. in contrast, the hydrophobicity of the elp impacted morphology; a hydrophobic elp resulted in spherical micelles, while a hydrophilic elp promoted the formation of worm-like structures [389] . [385] . dzuricky and coworkers expanded upon this work to observe how nanoparticle morphology impacted cell uptake [55] . a fibronectin type-iii (fn3) -binding domain that binds the α v β 3 integrin was fused to the c-terminus of an rlp-elp diblock copolymer. they found that the fn3 domain did not perturb self-assembly of the rlp-elp diblock copolymer, so that it was displayed on the nanoparticle surface upon self-assembly (figure 21) . the tunable morphology and high avidity of the rlp-elp-fn3 nanoparticles significantly improved the binding affinity to the α v β 3 integrin via multivalency. they found that shape played an important role in promoting multivalency though the avidity effect. while a spherical rlp-elp micelle that presented a fn3 a) j o u r n a l p r e -p r o o f domain showed a respectable 10-fold increase in affinity for the α v β 3 integrin compared to the monovalent rlpelp-fn3 unimer, the worm-like rlp-elp-fn3 nanoparticles showed a remarkable 1,000-fold increase in affinity for the integrin (figure 21 ) [55] . the combination of morphology and high avidity yielded a picomolar k d , a remarkable achievement considering that a therapeutic antibody against the same integrin exhibits a k d of only 20 nm. consequently, the worm-like rlp-elp-fn3 was more readily taken up by cells than the antibody [55] . these studies demonstrate that rlp-elp nanoparticles can be harnessed for robust, specific cellular targeting and uptake of therapeutic agents. because of their exquisite stimulus responsiveness and mechanical properties, rlps have been engineered as hydrogels for many biomedical applications. although many of the hydrogels were designed for use in tissue engineering applications, the principles derived from these studies can are also useful for the design of rlp-based controlled drug delivery systems. charati and coworkers reported an early example of a rlp hydrogel [390] . to test its utility for biomedical applications, they incorporated several biologically active domains into the sequence to control cell adhesion, hydrogel degradation, and biocompatibility. upon purification from e. coli, the protein was crosslinked with [tris(hydroxymethyl) phosphine] propionic acid (thpp), which linked the lysine residues in the rlp sequence. the resulting hydrogel was mechanically stable and capable of supporting hmscs and mouse nih-3t3 fibroblasts [390] . li and coworkers later evaluated the mechanical properties of rlp hydrogels more precisely and showed that the extent of thpp crosslinking impacts factors such as swelling ratio, elastic shear modulus, and resilience [391] . su and coworkers adapted rlps for cell adhesion by combining cell binding domains from fibronectin with a consensus sequence derived from a. gambiae. after it was crosslinked with tris(hydroxylmethyl)phosphine, the novel rlp scaffold exhibited mechanical properties consistent with those of rec1-resilin and a compression modulus comparable to that of cartilage [392] . the material supported mscs at 95% viability for up to 3 days, and the cells exhibited extensive spreading on the material surface [392] . while this hydrogel was primarily engineered j o u r n a l p r e -p r o o f for tissue engineering applications, it provides an example of how peptides can be appended to the rlp sequence for other biomedical applications such as drug delivery. other moieties, such as heparin [390, 391] , vegf-mimicking peptides [393] , and chitin -binding domains [394] , have similarly been appended onto rlps. in a reducing environment (b) , dextran release was not mw-dependent. in a non-reducing, pbs environment (c), dextran release was dependent on mw. adapted from [395] . taking advantage of the recombinant nature of rlps, su et al. engineered their novel rz10-rgd hydrogel to respond to changes in redox [395] . they used 3,3'dithiobis(sulfosuccinimidyl propionate) (dtssp), a redox-responsive crosslinker, to create rlp hydrogels that degrade in a reducing environment ( figure 22a) . various molecular weights of fitc-labeled dextran were loaded into the crosslinked rz10-rgd hydrogel. in reducing conditions, there was no observed difference in the release rates of dextrans with different molecular weights. in non-reducing conditions, release rate decreased with an increase in dextran mw (figure 22b ) [395] . the redox-responsiveness of this novel hydrogel makes it a promising candidate for tumor-specific drug delivery. other -smart‖ rlp hydrogels have been designed to degrade in response to elevated mmp concentrations [396] . when an mmp-sensitive domain was incorporated into a rlp sequence, the hydrogel underwent 90% degradation in the presence of physiological levels of mmps over the course of 48 rlp hydrogels without the mmp-sensitive domain did not degrade [396] . because the concentration of mmp-sensitive domains within the rlp hydrogel may be modulated to control degradation, this design can be adapted for drug delivery to tissues with elevated mmp concentrations, such as tumors or wound sites. resilin has also been combined with other proteins, including elastin, collagen, silk, and peptide amphiphiles (pas), to enhance the properties of rlps. bracalello and coworkers designed a chimeric polypeptide comprised of an rlp, elp, and clp in tandem, which they termed the rec polypeptide [397] . the purified material formed highly aligned fibrils that, over time, self-assembled into large fibers and fiber bundles. the fibers and bundles possessed a young's modulus of 0.1-3 mpa, which demonstrated that the material retained the elastic properties of resilin and elastin [397] . more recently, okesola and coworkers developed a highly tunable, multicomponent hydrogel using a covalent co-assembly strategy to combine an rlp with a peptide amphiphile (pa). this approach enabled control over the hierarchical self-j o u r n a l p r e -p r o o f assembly of the rlp hydrogel and enhanced its mechanical properties. the hydrogels were synthetized using a thiol-ene photoclick reaction and, depending on the pa concentration, assembled into a variety of nanostructures. in the absence of pa, the rlp hydrogels formed nanospheres upon photo-crosslinking, a low concentration of pa resulted in co-assembled beaded strings, and a high concentration of pa created co-assembled nanofibers. the photoclicked hydrogels maintained the remarkable elastic and energy-storing properties of rlp hydrogels, thus demonstrating that the co-assembly strategy can improve the mechanical properties of more brittle proteins such as pas. these results further support that rlp materials can be precisely tuned to achieve desirable properties for a drug release system. silk-elastin-like polypeptides, or selps, are block co-polymers consisting of tandem repeats of silk-like and elastin-like blocks [360] . these hybrid polypeptides combine the mechanical strength and chemical stability of silk with the unique thermal responsivity of elps, resulting in a material that can assemble into a variety of architectures ranging from nanomaterials to hydrogels [350] . like many other biopolymers, these materials are recombinantly produced, offering precise control over their length, the ratio of slp to elp blocks, and the ability to introduce biologically active molecules into the sequence [398] . an interesting characteristic of selps is their ability to undergo an irreversible sol-gel transition under physiological conditions, creating a matrix in situ that is useful for local delivery [360] . selps have been engineered to self-assemble into micellar structures that can be used as nanocarriers for drugs. the core of the micelle is formed by the slp blocks which form intermolecular hydrogen bonds to stabilize the micelle while the relatively hydrophilic elp forms the corona [361] . the hydrodynamic radius of the micelle can be tuned by altering the slp to elp block ratio or by altering the choice of guest residue in the elp block [361] . the self-assembly of selp nanoparticles may also be triggered by encapsulation of a hydrophobic drug. xia et al first explored this concept by mixing dox with selps with a slp to elp block ratio of 1:8, 1:4 or 1:2 [362] . the dox hydrophobically interacted with the silk j o u r n a l p r e -p r o o f domains, driving the formation of nanoparticles with hydrodynamic radii between 50 and 142 nm ( figure 23a) . these nanoparticles are in the appropriate size range to be passively targeted to solid tumors via the epr effect [399] . this approach is attractive as it avoids the need for harsh solvents and provides a respectable 6.5% drug loading efficiency [362] . dox-loaded selp nanoparticles enter hela cells via endocytosis rather than diffusion like free dox (figure 23b ). this allowed for potent accumulation of the drug in the cytoplasm and nearly 2-fold greater cytotoxicity than the free drug [362] . more recently, parker et al developed mucoadhesive selp nanoparticles for transmucosal drug delivery [400] . to identify potential mucoadhesive sequences, they generated a series of selps with a 1:4 slp to elp block ratio with four different guest residues -cys, arg, lys, and glu. these amino acids were chosen due to the potential of charged residues and thiol groups to interact with mucus. ans, a hydrophobic, solvatochromatic dye, was loaded into the nanoparticles via simple mixing to serve as both a model compound and reporter. in an in vitro biosimilar mucus model, the selp with cys guest residues demonstrated the strongest affinity for mucus, followed by selps containing lys, arg, or glu as the guest residue, respectively. interestingly, when incubated with mucus-secreting ht29-mtx cells, the cys-containing selp demonstrated little cell retention, suggesting it may have mucolytic properties. meanwhile, selps with charged guest residues were well retained by the cells, indicating their potential for transmucosal delivery. perhaps the most interesting property of selps is their ability to undergo a sol-gel transition under physiological conditions. these materials can be engineered to be soluble at room temperature, at which point drugs and other therapeutic molecules can be loaded by simple mixing without the use of toxic or denaturing solvents. upon injection, the material coacervates to form a polymeric matrix in situ. this property, along with the biocompatibility and j o u r n a l p r e -p r o o f sequence control of selps, makes them an attractive material for engineering local, controlled drug delivery systems. this approach was first explored by cappello et al in 1998 . in this study, fluorescently labeled macromolecules of varying molecular weights were loaded into selp hydrogels and their release rates were monitored [401] . for all compounds, release from the hydrogels was near first-order; however, there was no correlation between the release kinetics and the molecular weight of the molecule. this was attributed to the large size of the hydrogel pores, which are not small enough to impede diffusion [401] . the release rate decreased with an increase in selp concentration. the hydrogels were biocompatible when implanted in vivo with no sign of immunological activity or inflammation [401] . dinerman et al further evaluated the diffusion behavior of molecules out of selp hydrogels by using cytochrome c, theophylline, and vitamin b12 as model compounds [402] . they observed fickian, diffusion-controlled release behavior wherein diffusion slowed with an increase in molecular weight and polymer volume fraction [402] . due to the simplicity of drug loading and their gelation behavior, selps are also attractive materials for gene delivery. nucleic acids can be incorporated into the selp hydrogel by physical mixing, and upon injection, the selp hydrogel protects its cargo from rapid degradation while controlling the rate and location or release. this concept was first explored by megeed et al in 2002 using an selp containing positively charged residues. the negatively charged dna molecules electrostatically adsorbed onto the selp before injection [403] . they discovered that the release of dna was inversely related to the selp concentration and gelation time and that the ionic strength of the buffer directly correlated with dna release rate; as ionic strength increases, the greater concentration of counter ions disrupt the electrostatic interaction between the selp and dna, facilitating the release of the dna [403] . in a later study, megeed et al discovered that the release rate of plasmids from the selp hydrogel was inversely proportional to plasmid mw. furthermore, plasmid conformation impacted release rate, j o u r n a l p r e -p r o o f with linearized plasmids diffusing from the hydrogel fastest followed by supercoiled and circular plasmids, respectively [404] . the hydrogel maintained the stability and bioactivity of plasmid dna for 28 days and adenoviruses for 22 days. in an in vivo model with athymic nude mice bearing subcutaneous mda-md-435 tumors, mice treated with selps loaded with a plasmid for luciferase exhibited greater gene expression than mice treated with naked dna [404] . these studies aid the groundwork for selp design for dna delivery to treat cancer. hatefi et al loaded selp-47k, an selp comprised of four slp and 7 elp blocks with one elp block containing a lys substitution, with the adenoviruses ad.gfp or ad.cmv.lacz that encode green fluorescent protein (gfp) or β-galactosidase, respectively [405] . in an in vitro study, the selp hydrogel maintained the release of the adenoviruses over a 28 day period with only a 30-40% loss in virus activity ( figure 24a ) [405] . the ad.gfp-loaded selp was intratumorally showed significantly lower gfp expression than tumors receiving the selp formulation ( figure 24b ) [405] . this study demonstrated the potential of selps for adenoviral delivery to solid tumors. the ability of selp-815k to deliver adenoviruses was further tested in a head-to-head comparison with poloxamer 407, a commercially available synthetic copolymer used for gene delivery. both platforms were used to deliver a genetically encoded prodrug with an antiviral vector to a xenogenic model of hnscc. compared to poloxamer 407 and free virus, selp-815 exhibited the highest initial gene expression in tumors followed by prolonged expression for up to three weeks [406] . this high and sustained level of gene expression resulted in the greatest tumor size reduction and survivability across all groups. furthermore, selp-815k showed superior safety than poloxamer 407, as adipocytic necrosis was observed in animals treated with the latter [406] . a subsequent study demonstrated that, compared to free virus, virus-loaded selps also had reduced systemic toxicity [407] . more recent studies have provided new insights into the stability of viral vectors in selp hydrogels. two different selps were loaded with the oncolytic adenovirus ad-δb7-kox and evaluated with afm imaging to visualize the interaction between the adenovirus and selp j o u r n a l p r e -p r o o f nanofibers. afm showed that as adenovirus concentration increased, the density of the selp nanofibers also increased despite their fixed concentration [408] . this is likely attributed to the brownian motion of the adenovirus during assembly, as it acts as a stimulus for selp network formation. although most adenoviruses exhibited a round morphology for the first half-hour of being attached to selp, they began to deform after approximately 1 h. this is likely due to multiple strong interactions forming between adenovirus and different selp fibers [408] . it was also discovered that selp analogues with shorter elastin units exhibited lower temperature responsivity and more rapid elastase degradation [408] . with this fundamental understanding of selp degradation and adenovirus complexation, better gene delivery systems can be engineered from this material. selp hydrogels have also been used for sustained release of polysaccharides. the ghandehari group synthesized positively charged selp hydrogels that could electrostatically interact with an anionic polysaccharide -semisynthetic glycosaminoglycan ether (sage)-that is an anti-inflammatory drug for mucosa restoration. unfortunately when sage is administered, it does not achieve a high enough therapeutic concentration due to its insufficiently long residence time [409, 410] . to solve this problem for treatment of radiationinduced proctitis (rip), the ghandehari group designed an in situ gelling enema ( figure 25a ) [410] . in a murine model of rip, sage was present in the rectal tissue of mice 12 h after receiving a sage-loaded selp enema, while it was undetectable in mice receiving sage with saline ( figure 25b ) [410] . the ghanedhari group further adapted the selp platform for the sustained release of intravesically delivered sage for treatment of interstitial cystitis (ic) model. they found that employing a softer selp with a slower gelation time could provide an analgesic effect for 24 h without exacerbating the discomfort associated with ic, whereas stiffer gels could reduce the capacity of or obstruct the bladder [409] . j o u r n a l p r e -p r o o f more recently, researchers have focused on the design of de novo artificial polypeptides as drug carriers. these genetically engineered polypeptides are conformationally disordered, hydrophilic, and inert. like other protein polymers, they are recombinantly expressed and purified in bacterial systems, providing exquisite control over their length and sequence. they can also be genetically fused to therapeutic peptides or proteins to increase the half-life, stability, and biodistribution of their therapeutic partner. in addition to their stability and nonimmunogenicity, these hydrophilic biopolymers have long plasma circulation, making them an intriguing alternative to pegylation. in the last decade, two polypeptide sequences in particular-xten and pashave gained traction as biopolymeric drug carriers. the first xten molecule was designed and synthesized by schellenberger et al in 2009 [411] . to create a stable, soluble and unstructured stealth polymer, they eliminated hydrophobic amino acids known to contribute to aggregation or secondary structure formation, positively charged molecules that could bind cell membranes, and amide-containing residues that reduce stability. these criteria limited their pool of potential amino acids to sixalanine, glutamate, glycine, proline, serine and tyrosine. schellenberger et al then screened a library of nonrepetitive, randomized sequences to obtain an 864-residue biopolymer with optimal expression levels, yield, solubility, and stability [411] . this original xten molecule was genetically fused to exenatide, an antidiabetic peptide that has an in vivo half-life of 2.4 h. fusion to xten increased the peptide's half-life to 60 h in cynomolgous monkeys, with a predicted half-life of 139 h in a 75 kg human (figure 26 ) [411] . xten similarly enhanced the terminal half-life of gfp, human growth hormone, glucagon and factor vii. since this initial study, different mw variants of xten have been produced [412] and different functional groups for drug conjugationincluding azide, maleimide, and alkyne groups -have been introduced into the polypeptide [413] . xten has been similarly employed to counteract nocturnal hypoglycemia in diabetic patients. geething et al fused the biopolymer to gcg, a peptide hormone that converts glucagon stores into glucose but suffers from a minutes-long half-life and poor stability in liquid formulations [415] . in addition to improving the stability of gcg 60-fold, fusion to xten prolonged the efficacy of gcg in a fasted beagle dog model. gcg-xten provided strong resistance to a glucose challenge 6 h after prophylactic administration without affecting baseline blood glucose level [415] . the effect tapered off at 12 h post-administration, whereas free gcg was ineffective 2 h post-administration. xten also remarkably enhanced the pharmacokinetic profile of teduglutide, a glucagon-like peptide 2 analog used to treat an inflammatory malabsorption disorder in the small intestine with a half-life of ~3 h in humans [416] . the teduglutide-xten fusion achieved a 120 h half-life in cynomolgous monkeys, with a predicted half-life of 240 h in humans, further indicating how xten can be employed for once-monthly administration. the formulation also reduced the occurrence of ulcerations and presence of inflammatory cytokines j o u r n a l p r e -p r o o f in the small intestine [416] . additionally, this study was the first instance where the payload was chemically conjugated to xten; in this case, teduglutide was chemically conjugated via a cterminal cysteine residue. since then, xten has been chemically conjugated to other therapeutics including antivirals [412] and imaging agents such as annexin 5 [417] to improve their circulation time. xtenylation has been used to improve th p to human growth hormone (hgh), which typically suffers from an hours-long half-life and requires daily administration. somavaratan , an xtenylated formulation of hgh, achieved a half-life of 131 hr, a 30-60 fold increase compared to recombinant hgh in a phase i clinical trial (nct01718041) [418] . interestingly, fusion to xten reduced the potency of hgh 12-fold, yet the prolonged tissue exposure xten provided a 3 to 5-fold increase in efficacy compared to recombinant hgh [418] . in a phase ii clinical trial vista study (nct02068521), patients treated with somavaratan demonstrated increasing height velocity with increasing doses of the drug. and dose-dependent adverse events were minimal [419] . unfortunately , somavaratan failed to achieve the primary endpoint of non-inferiority versus genotropin, a recombinant formulation of hgh, in a phase iii velocity clinical trial (nct02339090) for pediatric patients with growth hormone deficiency. a phase ii clinical trial (nct02526420) has also been completed for growth hormone deficiency in adults. these studies demonstrate the promise of xten in improving drug half-life, bioavailability, and efficacy. [420] . more recently, a von-willebrand factor independent fviii-xten fusion, termed bivv001, has demonstrated good safety and efficacy in early stage clinical trials (nct03205163) and is currently recruiting for phase 3 (nct04161495) [421, 422] . xtenylation of fviii increases its plasma half-life three to four-fold relative to recombinant fviii, achieving a half-life of up to 34 h in cynomolgous monkeys [423] . this resulted in four-fold longer hemostatic control, suggesting that this formulation could provide clotting protection for patients for up to one week [423] . xten's large size has also been harnessed to take advantage of the epr effect to passively deliver anticancer therapeutics to tumors. to demonstrate its utility, haeckel et al designed a multicomponent fusion protein to improve the delivery of killin, a cytostatic and cytotoxic protein [424] . despite the promising antitumor effects of killin, its expression in bacterial systems was impossible due to its toxicity. c-terminal fusion to xten deactivated the protein so it could be stably expressed and purified. upon administration, xten would further serve to enhance the circulation time of killin and exploit the epr effect for tumor-specific targeting. a matrix metalloproteinase cleavage site was incorporated between the xten and killin, allowing the killin to be released and activated upon tumor penetration. to improve cell membrane penetration and dna binding, a cell penetrating peptide (cpp) was also added onto j o u r n a l p r e -p r o o f the c-terminus of killin [424] . the fusion protein was preferentially taken up into cancer cells with high mmp-2 or mmp-9 expression. this xten-killin-cpp fusion also arrested growth and induced concentration-dependent apoptosis in killin-sensitive cell lines, with the effect peaking at 48 h after treatment [424] . this study demonstrates the potential of xten as a carrier for anticancer therapeutics. this concept has recently been adapted by amunix to develop xtenylated protease-activated t-cell engagers, or xpat. in this technology, the bispecific t-cell engager blincyto, which engaged cd3 and and cd19, is xtenylated to reduce its immunogenicity. tandem protease recognition sites are incorporated between the xten chain and tandem scfvs of the bispecific t-cell engager to promote its release upon protease exposure. this technology has been adapted to target her2+ (amx-818) and egfr+ cells [425] . in recent pre-clinical studies, these fusions achieved picomolar affinity ec50s against cell lines expressing their target proteins while reducing t-cell toxicity 15,000-fold. they also induced significant proteasedependent tumor regression in xenograft models. her2-and egfr-xpat were also well tolerated by cynomolgous monkeys, with a 1000-fold greater c max for the her 2-xten fusion and a 100-fold greater c max for the egfr-xpat than their non-xtenylated counterparts [425] . a second recombinant polypeptide, termed pas, was engineered by xl-protein gmbh company in 2013 and is conceptually similar to xten [426] . both are intrinsically disordered, hydrophilic polypeptides that are designed to enhance the plasm half-life of fused proteins and peptides [426] . pas are reported to be non-immunogenic, biodegradable, and are produced in bacterial systems [426] . their recombinant synthesis enables precise control over their sequence and length enable gene-level fusion to a therapeutic peptide or protein of interest in order to enhance the pharmacokinetic profile of the fusion partner [427] . whereas xten incorporates negatively charged residues and consists of pro, tyr, glu, gly, ala and ser, pas do not contain charged amino acids and their sequence is limited to pro, j o u r n a l p r e -p r o o f journal pre-proof ala and ser [427] . in the initial study published by xl-protein gmbh company, pas was recombinantly fused to three proteins -a recombinant fab region of a humanized anti-her2 antibody, human interferon a2b, and human growth hormone-to evaluate its utility as a drug delivery carrier. fusion to pas increased the hydrodynamic volume of the cargo up to 26-fold and extended the blood circulation of the fusions [426] . the plasma half-life and auc of pasylated ifn was 32-fold and 100-fold greater than the non-pasylated ifn and the protein's binding affinity for its receptor was not affected by fusion to pas (figure 27a) . similarly, pasylated hgh exhibited a 94-fold greater plasma half-life than control hgh and exhibited a 3fold greater growth promoting effect than native hgh on an equimolar basis ( figure 27b ) [426] . since this initial study, pasylation has been employed to enhance the half-life and pharmacokinetics of numerous therapeutics. like other biopolymers, many applications that harness pasylation require long-lasting therapeutics to reduce dosing frequency and side effects. as such, xl-protein gmbh company has developed several formulations to improve the therapeutic efficacy of several peptides for the treatment of many diseases, including exendin for type ii diabetes, hgh for pediatric growth hormone deficiency, and anti-inflammatory agents for rheumatoid arthritis [428] . many of these fusions are currently in preclinical trials. other groups have also explored pasylation as a strategy to improve the circulation and efficacy of interferons for the treatment of multiple sclerosis. in a study conducted by harari et al, a superagonistic analog of ifnβ, ynsα8, was fused to the c terminus of a 600 amino acid pas polypeptide chain [429] . when administered to a transgenic mouse model harboring humanized ifnar receptors (hybnar model), pas-ynsα8 exhibited a 10-fold increase in half-life compared to ynsα8 alone without impacting the biological activity of the superagonist. despite being administered at an overall 16-fold lower dosage than ifnβ alone, pas-ynsα8 outperformed the control group in an experimental autoimmune encephalomyelitis model, as indicated by a decrease in infiltrating macrophages in the central nervous system and an increase in regulatory t cells [429] . in a separate study by zvonona et al, pas was fused to the j o u r n a l p r e -p r o o f journal pre-proof c-terminus of ifn-β1b and resulted in a 4-fold increase in hydrodynamic radius compared to free ifn-β1b [430] . the fusion protein also notably increased ic50 2-fold compared to free ifn-β1b, an accomplishment considering pegylation of the same interferon decreases its activity. furthermore, this formulation was stable when stored for 22 months at -20°c, indicating how pasylation can contribute to the maintenance of biological stability [430] . similarly, pasylation has contributed to the improved half-life and efficacy of numerous proteins including leptin [431, 432] , erythropoietin [433] , conversin [434] and clotting factor viii [435] . pasylation has also been harnessed to improve the delivery of nanocarriers, most notably for the treatment of cancer. in one study, pas 40 or 75 residues long were recombinantly fused to ferritin, an iron storage protein that self-assembles into a hollow sphere and binds internalizing transferrin receptor i, which is upregulated on many cancer cells [436] . pasylation stabilized the ferritin during purification and drug loading, resulting a greater yield of nanocarriers and 3-fold higher dox loading. the half-life of the pasylated nanocarrier was 5fold greater than that of the control nanocarrier and 55-fold greater than that of free dox [436] . the same research group further developed this platform by incorporating an mmp-cleavable linker between pas and ferritin. this design resulted in a 5-6 fold decrease in affinity between ferritin and its receptor, transferrin receptor i. thus, healthy cells with low expression of transferrin receptor i were not affected by the encapsulated dox [437] . upon exposure to high mmp concentrations in the tumor microenvironment, the pas shield was cleaved from the ferritin, increasing the affinity of the nanocarrier for its target. in mice bearing xenogeneic paca-44 pancreatic tumors, treatment with the pasylated formulation led to 4-fold greater tumor regression than a non-pasylated nanocarriers and 8-fold greater regression than seen with free dox, respectively [437] . these studies indicate how pasylated nanocarriers can be used to improve drug potency while reducing off-target effects. pasylation is also useful for nucleic acid delivery by providing stealth behavior to the delivery system. morys et al conjugated short pas sequences only four repeats long to polyethylenimine, a cationic polymer frequently employed in nucleic acid delivery systems [438] . the pas provided enough hydrophilicity to prevent aggregation and dissociation of the pei/dna polycomplexes. furthermore, pasylation of the pei-dna complex prevented interaction with blood serum proteins, preventing polyplex opsonization and clearance in vivo [438] . although this system needs further optimization for in vivo gene transfer, this study indicates that pasylation is potentially a useful strategy for improving the stability and delivery of nucleic acids. gliadin is a gluten protein extracted from wheat. its monomeric form, which has a mw of 25-100 kda, is up to 70% soluble in alcohol, and its polymeric form, which has a mw of 106 kda, contains a high level of disulfide bonds that renders it largely insoluble [439] . as such, gliadin materials show excellent stability without the need for toxic crosslinking agents. gliadin is rich in neutral residues that provide it with mucoadhesive properties and make it an ideal platform for oral drug delivery [440] . gliadin also contains many lipophilic residues that allow it to protect its cargo for prolonged release and hydrophobic interaction with tissues, including skin. due to its apolarity, gliadin has been most useful as a carrier for hydrophobic or amphiphilic drugs [441] . the solubility, hydrophobicity, and bioadhesive properties of gliadin contribute to its ability to sustain the release of therapeutics in drug delivery applications. polymeric gliadin has been widely explored as a material for nanoparticulate systems targeting the gastrointestinal mucosa. arangoa et al. demonstrated that upon oral administration of the lipophilic molecule carbazole in a gliadin nanoparticle to mice, the gliadin delivery vehicle improved drug adsorption through the stomach mucosa [442] . this phenomenon resulted in a sustained carbazole concentration in circulation and improved bioavailability. further research evaluated gliadin as a nanoparticulate carrier for the anti-cancer drug cyclophosphamide [443] . after loading cyclophosphamide onto the nanoparticles with a remarkable 72% loading efficiency, gulfam et al. demonstrated that the drug was released in a two-step manner. after a brief period of rapid release from the nanoparticles, cyclophosphamide was steadily released over the course of 48 h and induced apoptosis in breast cancer cells, which highlighted the utility of this system utility as a carrier for anti-cancer therapeutics [443] . because gliadin nanoparticles improve drug penetration into the gastric mucosa, it has been extensively engineered to protect and deliver antibiotics to the stomach to treat helicobacter pylori infections [51] . ramteke et al. loaded gliadin nanoparticles with clarithromycin and omeprazole via a desolvation technique [51] . the nanoparticles showed sustained release of the drugs at an acidic ph that mimicked conditions in the stomach and were more effective in eradicating h. pylori in vitro than free drug. in a similar study, umamaheshwari et al. demonstrated that gliadin nanoparticles increased the gastrointestinal residence time of amoxicillin, thus necessitating a lower dose to eradicate h. pylori infection than the free drug in a mongolian gerbil model [444] . these studies indicate that the bioadhesive properties of gliadin can be leveraged to improve gastric absorption and drug availability. another abundant source of plant protein is the soybean, from which soy protein isolate (spi) is extracted. spi contains glycinin and β-conglycinin, which compose nearly 60% and 40% of the protein, respectively [445] . these proteins exist as globular structures in an aqueous environment and aggregate upon the addition of a crosslinking agent or solvent [446] . this can drive the formation of hydrogels, polymer blends, or microspheres. moreover, because spis are enriched in glutamine, aspartic acid, and leucine that offer a variety of secondary bonding interactions, many types of drugs can be incorporated onto the proteins for delivery purposes. [447] . engineered soy nanoparticles to sequester and relase curcumin [448] . they prepared the nanoparticles using a desolvation technique and achieved an encapsulation efficiency of 97%. curcumin release from the nanoparticles followed a biphasic trend. initial burst release was observed as the nanoparticles swelled, followed by sustained release [448] . the pharmacokinetics, gastrointestinal uptake, and encapsulation efficiency of soy nanoparticles have also been improved by combining the protein with other materials such as folic acid [449] , zein [450, 451] , or alginate [452] . spi films have also been engineered to release a variety of drugs to treat bacterial infections and promote wound healing. in one example, peles et al. incorporated the antibiotic gentamicin into the matrix of an spi film prepared by solvent-casting. after an initial period of burst release, gentamicin exhibited prolonged release over the course of four weeks [453] . other studies have explored various crosslinking agents to improve the structural integrity and degradation kinetics of spi films. to circumvent the toxicity associated with chemical crosslinkers, song et al. employed genipin, a natural crosslinking agent, to control the swelling ratio and enhance the strength of the film [454] . films crosslinked with genipin exhibited slowed release rates of bsa, the model protein drug, compared to spi films without genipin. furthermore, the film exhibited ph-sensitivity that could be employed for delivery to the gastrointestinal tract [454] . chen et al. also designed spi films to release drug in the gastrointestinal tract by using formaldehyde as a crosslinking agent [455] . formaldehyde crosslinking increased the tensile strength of the film. methylene blue -a model drug-and rifampicin-and antibiotic -interacted strongly with the spi such that they were not released until bulk erosion occurred, which was accelerated by gastric enzymes [455] . another ph-sensitive spi film was engineered by vaz et al. using glyoxal as a crosslinking agent for spis produced via a melt extrusion technique [456] . because the pi of soy protein isolate is between 4.3-4.8, rapid release of the model drug theophylline was observed at a ph of 5, as there was little interaction between the drug and soy. at physiological ph, however, soy protein isolate was negatively charged and more strongly interacted with the drug than in acidic conditions , thereby slowing its release [456] . spi fibers have also been investigated as a drug delivery scaffold. xu et al. studied the sorption, kinetics and thermodynamics of drug release from spi fibers for three different drugs [457] . as the temperature was increased, the diffusion coefficient of drug sorption onto the fibers increased. for metformin and diclofenac, sorption and release relied on the ionic interactions j o u r n a l p r e -p r o o f between the drug and spi scaffold. conversely, these parameters were governed more strongly by van der waals forces for drugs such as 5-fluorouracil. for all model drugs, burst release was controlled by altering the drug-loading concentration. because release relies on the affinity of the drug for the spi, a lower loading concentration resulted in less burst release [457] . collectively, these studies demonstrate that spi vehicles can be designed and tuned to deliver a variety of therapeutics. zein, the major storage protein in corn, is a low-molecular weight protein in maize endosperm [458] . depending on its molecular weight and extraction process, zein is classified asα-zein, β-zein, γ-zein, or δ-zein. the most abundant form, α-zein, is a 22-to 24-kda protein that forms a triple super-helix [459] . though the structure is not fully elucidated, small-angle xray scattering data suggests that nine or ten homologous, helical repeating units arrange into an anti-parallel helix that is stabilized by hydrogen bonding [460, 461] . all classes of zein are rich in alanine, leucine, proline, and glutamine residues, but α-zein is the most frequently used class in drug delivery applications due to its abundance. though zein contains both hydrophilic and hydrophobic regions, its large fraction of non-polar residues makes it insoluble in water without the addition of alcohol, urea, or anionic or alkaline surfactants [459] . the hydrophobicity of zein also renders it mucoadhesive [462] . zein has been incorporated into -smart‖ hydrogels to control the release of drugs in response to a biological or environmental stimulus. liu et al. generated complex hydrogel beads composed of zein and pectin [463] . the hydrophobic zein suppressed bead swelling in physiological conditions, while pectin protected the zein from protease degradation in the gastrointestinal tract, thus promoting colon-specific drug delivery [463] . zein has also been engineered into an injectable, biodegradable gel that forms in situ. gao [464] . when administered to venous malformations as a sclerosant, the zein-saib hydrogel provided four days of prolonged drug release [464] . zein hydrogels have also been designed for sustained release of chemotherapeutics and reduce their off-target effects. cao et al. demonstrated that an intratumoral injection of an in situ zein hydrogel extended the release of entrapped dox, resulting in increased anti-tumor efficacy [465] . they also showed that dox release could be modulated by adjusting the zein concentration [465] . most zein-based materials for drug delivery have been microspheres or nanoparticles. zein is rich in nonpolar residues, which allows it to stably complex with drugs and entrap them in j o u r n a l p r e -p r o o f the nanoparticle core. the first reported zein microparticle was designed by matsuda et al. to improve the therapeutic index of polysaccharide-kureha (ps-k), a protein polysaccharide that stimulates anti-cancer immune activity [466] . monodisperse microspheres were generated by sonication and produced 1-µm microspheres that could be phagocytosed by macrophages [466] . subsequent studies by this group involved combinations of zein with three other anti-cancer drugs to improve their pharmacokinetics, which demonstrates the versatility of the platform [467] . since then, zein microparticles have been engineered to deliver antibiotics such as ciproflaxin [468] , anti-parasitic drugs such as ivermectin [458] , and corticosteroids such as prednisolone [469] . muthuselvi et al. investigated how the solvent used for microsphere fabrication impacts drug release [470] . using the cardiotonic glycoside gitoxin as a model drug, they fabricated zein microspheres with ethanol, methanol, and isopropanol mixtures. while microspheres made with methanol and isopropanol rapidly released the drug over four days, microspheres prepared with ethanol exhibited biphasic release. following an initial phase of burst release, drug release was sustained for 80 h before tapering off into a slower, final stage of release [470] . their ability to harness the epr effect provides another reason for the use of zein nanoparticles in chemotherapeutics. in one example, lai et al. loaded zein nanoparticles with 5fluorouracil for delivery to the liver [471] . when labeled with rhodamine-b intravenously administered, the zein nanoparticles increased liver-targeting efficiency 31% vs. free rhodamine b and 5-fluorouracil uptake in the liver was ~3-fold higher than that of free drug [471] . dong et al. loaded zein nanoparticles with dox and achieved 90% loading efficiency [472] . dox release was ph-dependent, with more rapid release occurring in acidic conditions. confocal laser scanning microscopy in hela cells showed that the zein nanoparticles were effectively endocytosed into the cytoplasm and that smaller nanoparticles could enter the nucleus [472] . improve the anti-cancer potency of statins using lovastatin as the model drug [473] . lovastatin-loaded zein nanoparticles promoted anti-proliferative activity in hepg2 cells by accumulating in the cytoplasm during the g2/m and pre-g phases of mitosis [473] . further, zein nanoparticles have improved the pharmacokinetics, solubility, and potency of anti-tuberculosis drugs-including rifampicin, pyrazinamide, and isoniazid [474] -and vitamin d3 [475] . caseins are milk proteins that evolved from a family of secreted calcium (phosphate)binding phosphoproteins [476] . accounting for nearly 80% of all bovine milk proteins, caseins j o u r n a l p r e -p r o o f exist in four different forms -αs1, αs2, β-, and κ [477, 478] . though they are all amphiphilic and proline-rich, the four caseins differ in their overall amino acid, phosphorous, and carbohydrate content [479] . caseins are naturally unstructured, which endows them with the flexibility to exhibit intermolecular interactions. consequently, they assemble into micelles 50-500 nm in diameter with negatively charged surfaces [479] . the size distribution of these micelles is readily impacted by environmental factors, including ph, ionic strength, and hydrostatic pressure, due to their amphiphilicity and lack of tertiary structure [480, 481] . although they withstand high temperatures of up to ~71°c, they are quickly destabilized by acidic environments, which makes them a good option for oral delivery [482] . because casein naturally takes on a micellar conformation, it has been readily adapted as a drug nanocarrier. an early example of this idea was demonstrated by semo et al. they encapsulated the fat-soluble vitamin d2 in the core of casein micelles and demonstrated that the casein barrier protected vitamin d2 from uv degradation [483] . soon after this finding was published, casein micelles were used to entrap poorly soluble chemotherapeutics, such as curcumin. in this study, sahu and coworkers used steady state fluorescence spectroscopy to show that curcumin shows hydrophobic interactions with casein. the complexes self-assembled into micelles ~166 nm in diameter, which were efficiently internalized by hela cells [484] . the ph-sensitivity of casein nanoparticles also makes them useful for gastrointestinal delivery. the livney group loaded β-casein nanoparticles with the chemotherapeutic drug mitoxantrone to create stable nanoparticles 100-300 nm in diameter that clustered to trap the drug between micelles as well as within their cores [485] . these micelles rapidly disintegrated in an acidic microenvironment, suggesting their potential for targeting gastric cancer [486] . casein micelles have similarly been adapted to improve the bioavailability and targeting of other drugs, such as dox [487] , folic acid [488] and flutamide [489] . casein films have also been applied to tablets to slow drug release. these films, which are typically prepared with transglutaminase as the crosslinker, exhibit remarkable tensile strength, and are gradually hydrolyzed by chymotrypsin [490] . abu diak and coworkers coated diltiazem-hcl tablets with casein using four different plasticizing agents and ultimately derived a continuous tablet coat with oleic acid as the olasticizer [491] . at ph 1.2, casein-coated tablets slowed the release of diltiazem-hcl compared to uncoated tablets, which released 80% of drug within 2 h. the rate at which the coated tablets released the drug decreased with increasing post-coating heat treatment temperature. similarly, at ph 6.8, only coated tablets that underwent j o u r n a l p r e -p r o o f post-coating heat treatment at 100°c successfully showed sustained drug release, which was likely due to casein crosslinking under these conditions [491] . the favorable hydrophilicity and biocompatibility of casein, coupled with the availability of reactive sites for chemical modification within its sequence, make it an ideal material for forming hydrogels. in an early example, song and coworkers created genipin-crosslinked casein hydrogels to encapsulate bsa [492] . hydrogel swelling and subsequent bsa release was governed by the environmental ph. at ph 1.2, there was minimal hydrogel swelling and the bsa remained entrapped in the gel. when the ph was increased to 7.4, the hydrogel swelled and released greater amounts of bsa, making this hydrogel useful for intestinal delivery. the swelling behavior was similarly influenced by the degree of crosslinking by genipin [492] . in a later study, the same group employed microbial transglutaminase to crosslink casein hydrogels into a fractal network structure compared to uncrosslinked casein hydrogels [493] . vitamin b 12 , was loaded into the hydrogel under mild conditions and was slowly released from the hydrogel at ph 7.4. the rate of release slowed with increased crosslinking [493] . casein-drug composites have also been designed to improve the solubility and dissolution of various drugs. millar and corrigan first demonstrated that freeze-dried compacts made from sodium caseinate and acidic casein enhanced the dissolution rates of chlorothiazide and hydrochlorothiazide 35-fold and 1.5-fold, respectively. the improvement in dissolution was related to the complexation with casein and processing of the drug [494] . millar et al. further characterized the dissolution rate of the compacts over a range of compositions and found that the dissolution rate of acidic casein was half that of sodium caseinate [495] . using ibuprofen as the model drug, they showed that acidic casein compacts significantly slowed drug dissolution compared to sodium caseinate compacts. they attributed the difference to the changing form of casein that took place due to microenvironmental ph differences in the boundary layer. acidic casein was also more viscous and rigid than sodium caseinate, which decreased its solubility and reduced drug diffusivity [495] . a subsequent research group demonstrated that acidic casein and sodium caseinate could be mixed with other materials, such as hydroxypropylmethocellulose matrices, to slow drug dissolution [496] . iron binding proteinsmost notably transferrin and ferritinhave been widely explored as drug delivery vehicles due to the increased need for iron in many diseases, including cancer. in these applications, iron binding proteins serve to both improve the pharmacokinetics and stability of j o u r n a l p r e -p r o o f their cargo, but also to target the drug by taking advantage of the body's natural iron transport mechanisms. transferrin is an abundant glycoprotein that plays a critical role in the systemic transport of iron. as a natural iron-chelating agent, it reversibly binds one or two ferric ions to maintain their solubility and prevent toxic free-radical generation [497] . it also promotes iron endocytosis by binding the transferrin receptor 1, which is upregulated on malignant cells to meet their increased iron needs [498] . transferrin receptor 1 is also expressed on brain endothelial cells, making transferrin an attractive option for delivering therapeutic cargo across the blood brain barrier [499] . it should be noted that, due to its unique targeting capacity, transferrin has been used as a targeting moiety to deliver both small molecule chemotherapeutics and peptides/proteins. transferrin-drug conjugates have been employed to target chemotherapeutics to tumors delivery and reduce the off-target toxicity of the drug. szwed et al coupled dox to transferrin and showed that transferrin could overcome anthracycline resistance by impairing the pglycoprotein activity in several anthracycline-resistant cell lines such as dox resistant k562 cells [500] . in a subsequent study, they demonstrated that a dox-transferrin conjugate successfully induces apoptosis in leukemia cells while avoiding toxicity to non-malignant cells [501] . transferrin was also used to target cytochrome c to lung tumors by conjugating it to transferrin using sulfo-lc spdp as a crosslinker [502] . this strategy resulted in nanocarriers ~10 nm in diameter, allowing them to avoid rapid kidney filtration. upon endocytosis by cells, the redox-sensitive bond in the linker was cleaved, releasing cytochrome c from transferrin and initiating apoptosis [502] . transferrin based nanoparticles have also been engineered to deliver photothermal and photodynamic agents for cancer therapy. wang et al treated transferrin with dtt, leading to exposure of hydrophobic residues that could interact with the near-infrared dye ir780 through hydrophobic interactions [503] . these dye-loaded nanoparticles had a half-life of 20 h and were j o u r n a l p r e -p r o o f readily endocytosed by malignant cells within 2 h. they accumulated in which tumor with a high tumor-to-background ratio and, when pulsed with an 808 nm laser, caused a temperature increase to 49.5°c that caused tumor regression, whereas tumors treated with pbs only showed a temperature increase to 36.3°c, which had no effect on tumor growth [503] . this study demonstrates how transferrin could be used to enhance the pharmacokinetics and delivery of hydrophobic agents. transferrin has similarly been fused to glp-1 to improve the with improved pharmacokinetics of this peptide drug for treatment of type 2 diabetes [504] . this technology, developed by biorexis and later acquired by pfizer, consists of non-glycosylated transferrin genetically fused to glp-1, creating a fusion protein that is expressed in yeast cells. fusion with transferrin did not affect the insulinotrophic properties of glp-1 and yielded a half-life of 1-2 days, compared to a half-life of minutes for native glp-1 [504] . furthermore, the glp-1transferrin fusion promoted greater β-cell proliferation and β-cell area compared to transferrin alone. two days after receiving an intraperitoneal injection of glp-1-transferrin, treated mice demonstrated a significant increase in β-cell proliferation with nearly 10% of total islet cell possessing brdu+ nuclei. meanwhile, β-cells in animals treated with transferrin alone did not show signs of proliferation after two days [504] . as such, glp-1-transferrin may provide a novel strategy for restoring β-cell function in diabetics while maintaining blood glucose control. transferrin has also been exploited to treat autoimmune diseases such as myasthenia gravis (mg). in patients with mg, autoantibodies recognize and block nicotinic acetylcholine receptors (achr). by fusing the α-subunit of achr to transferrin, keefe et al created shg2210, a fusion protein that is recognized and bound by anti-achr autoantibodies and is internalized by cells via the transferrin receptor [505] . results from in vitro binding and internalization studies show that anti-achr autoantibodies bind shg2210 with an ic50 of 0.37 µm, while no binding to transferrin alone was observed [505] . when the shg2210:antibody complex was added to hela cells in culture, the complex was readily internalized via the transferrin receptor, as seen by the j o u r n a l p r e -p r o o f negligible uptake by the cells in the presence of saturating levels of a soluble achr inhibitor. after internalization, the complex was trafficked to the lysosome and was degraded [505] . transferrin delivery platforms were further optimized by chen et al, who evaluated the effect of various linkers on the binding affinity and pharmacokinetics of transferrin fusion proteins. in this work, growth hormone (gh) or granulocyte colony-stimulating factor (g-csf) were genetically linked to transferrin via a dipeptide linker, a helical peptide linker, or a thrombincleavable, disulfide cyclopeptide linker [506] . for both gh-tf and g-csf-tf, the longer -helical or cyclopeptide linkers-linkers resulted in less steric hindrance and thus provided greater binding affinity between gh or g-csf and their receptors as well as transferrin and its receptor. fusion proteins with the highest affinity for their targets also had the greatest plasma half-life [506] . the fusion containing the cyclopeptide linker had the greatest affinity for the transferrin receptor (ic50 of 0.9 nm) and achieved a half-life of 5.7 hr. in contrast, the fusion with the dipeptide linker had an 8-fold lower affinity for the transferrin receptor and exhibited a shorter half-life of 4.2 hr [506] . this study demonstrates how delivery of a protein drug via a transferrin carrier can be modulated by tuning the length and type of linker between the transferrin and its cargo. like transferrin, ferritin has also been exploited to target and carry drugs. ferritin is an iron-storage protein composed of 24 subunits that assemble into a spherical nanocage [507] . while this nanocage naturally houses up to 4500 iron atoms, it can also be engineered to house a variety of therapeutics [508, 509] . its loading capacity depends on several factors, including mw of the drug, the encapsulation strategy, and choice of co-solvent for entrapping drugs. metal salts achieve the highest encapsulation efficiency with nearly 5000 particles of agno 3 fitting in a single cage, whereas small, hydrophobic moleculesincluding many chemotherapeutics, exhibit lower loading efficiency [510, 511] . taking advantage of ferritin's natural ability to traverse the blood brain barrier, fan et al loaded a ferritin nanocage with an infrared dye and administered it to mice bearing u87mb j o u r n a l p r e -p r o o f orthotopic gliomas [512] . accumulation of the ferritin nanocage in the glioma-bearing mice was 10-fold greater than in the control group that received the dye alone, with maximum accumulation 4-6 hr after administration. interestingly, nanocage accumulation was limited to the tumor and no significant accumulation was observed in healthy brain tissue [512] . fan et al then loaded the nanocages with dox. and administered them intravenously. the dox-loaded nanocages nearly doubled survival time compared to treatment with free dox and significantly reduced tumor volume. additionally, mice treated with the dox-loaded nanocages exhibited slowed weight loss, indicating that the formulation reduced toxicity compared to free dox [512] . in a separate study, dox loaded ferritin nanocages increased the half-life of dox 12-fold and the auc by over 100-fold [513] . ferritin nanocages have also been used to deliver the poly adp ribose polymerase inhibitor olaparib to treat multiple forms of breast cancer. a study conducted by mazzucchelli et al demonstrated that the encapsulation of the drug in a ferritin nanocage led to 1000-fold greater uptake of the drug by triple negative breast cancer cells compared to the free drug [514] . the nanocage enhanced the cytotoxicity of the drug in cancer cells and reduced off-target toxicity in healthy cells. these studies demonstrate that ferritin nanocages can be harnessed to improve the delivery of chemotherapeutics in a variety of cancers. in another application, jiang et al synthesized a cobalt nanozyme -a nanomaterial with intrinsic enzyme-like activity -within a ferritin nanocage [515] . synthesis of the nanozyme within the confines of the nanocage provided better control over the size and structure of the nanozyme compared to nanozymes synthesized outside of the nanocage. the hepatocellular carcinoma targeting peptide sp94 was recombinantly fused to ferritin such that it was displayed on the nanocage exterior for optimal targeting [515] . though this design was used for diagnostic purposes, the remarkable targeting specificity it achieved demonstrates how it can be readily adapted as a drug delivery vehicle. ferritin nanocages can also be employed to deliver nucleic acids. li et al successfully encapsulated sirna into the nanocage, protecting it from rapid in vivo degradation [516] . this j o u r n a l p r e -p r o o f system exhibited highly efficient transfection into primary human tumorigenic cell lines, pmbcs, and mesenchymal stem cells. notably, up to 85% gene knockdown was achieved by the nanocage, while lipofectamine -the gold standard-only achieved 40% gene knockdown [516] . at the low sirna concentration of 10 nm used in this study, lipofectamine is relatively inefficient at transfection as it requires a higher sirna concentration for optimal activity, whereas the nanocage is more effective at gene knockdown at this low sirna concentration. because the biophysical properties and encapsulation of sirna are sequence-independent, this approach could be adapted for sirna delivery for numerous applications [516] . the research discussed in this review highlights the versatility and multifunctionality of protein-based materials for drug delivery. these carriers benefit from exceptional biocompatibility and biodegradability and minimal toxicity. most importantly, protein-based materials are highly customizable. their chemical, physical, and biological properties can be tailored for a specific application with sequence-level precision, thus providing the researcher with full control over the formulation's pharmacokinetics, pharmacodynamics, biodistribution, and in vivo interactions. much of this work has been made possible by continuing advances in genetic engineering and synthetic biology, which have made it possible to incorporate new chemistries and structural motifs into the polypeptide sequence to improve drug conjugation, targeting, stimulus responsiveness, and self-assembly. researchers continue to explore new ways to engineer proteins to possess desirable chemical and mechanical properties. one such strategy is to create hybrid materials by combining a protein with other proteins or synthetic components to generate a material with the favorable physicochemical properties of its building blocks. another method focuses on conferring new functionalities onto proteins through chemical processing, post-translational modification, or the incorporation of unnatural amino acids into the protein sequence. this approach expands the range of drugs that can be recombinantly fused to, chemically conjugated to, or physically encapsulated by the material. new protein-based materials also continue to be developed from existing proteins and by de novo design of peptide sequences that can introduce new attributes to protein materials to improve drug delivery. as researchers continue to make progress in adapting existing and developing new protein materials, there is also great opportunity for biological and materials science research that will maximize the clinical success of protein drug carriers. despite the progress made in this field, formulations using protein-based materials rarely reach or survive clinical trials. they are hindered by poor in vivo stability and performance, which results from an insufficient understanding of how to create materials that remain stable and functional in the harsh environments present during storage, administration, and circulation. this is further highlighted by the fact that, even though the half-life of a drug can be significantly increased by its protein carrier, the half-life of the 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gelatin and polyvinyl alcohol bioprintable alginate/gelatin hydrogel 3d in vitro model systems induce cell spheroid formation engineering bioprintable alginate/gelatin composite hydrogels with tunable mechanical and cell adhesive properties to modulate tumor spheroid growth kinetics directing the self-assembly of tumour spheroids by bioprinting cellular heterogeneous models within alginate/gelatin hydrogels in vitro microbial inhibition, bonding strength, and cellular response to novel gelatin-alginate antibioticreleasing soft tissue adhesives novel gelatin/alginate soft tissue adhesives loaded with drugs for pain management: structure and properties fibrous proteins: coiled-coils, collagen and elastomers elastin-based materials applications of elastin-like polypeptides in drug delivery elastin-like polypeptides: biomedical applications of tunable biopolymers molecular description of the lcst behavior of an elastin-like polypeptide ucst and lcst behavior in polymer blends a unified 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drug delivery strategies: review of recent advances and business prospects drug delivery systems: an updated review optimization of elastin-like polypeptide fusions for expression and purification of recombinant proteins in plants elpylated anti-human tnf therapeutic singledomain antibodies for prevention of lethal septic shock influence of elastin-like polypeptide and hydrophobin on recombinant hemagglutinin accumulations in transgenic tobacco plants drug delivery in stealth mode stealth properties to improve therapeutic efficacy of drug nanocarriers long circulating genetically encoded intrinsically disordered zwitterionic polypeptides for drug delivery thermo-reversible self-assembly of nanoparticles derived from elastin-mimetic polypeptides self-assembly of block copolymers derived from elastinmimetic polypeptide sequences thermoplastic elastomer hydrogels via self-assembly of an elastin-mimetic triblock polypeptide temperature triggered self-assembly of polypeptides into multivalent spherical micelles a quantitative recipe for engineering protein polymer nanoparticles elastin-like polypeptide diblock copolymers self-assemble into weak micelles morphing low-affinity ligands into highavidity nanoparticles by thermally triggered self-assembly of a genetically encoded polymer digital switching of local arginine density in a genetically encoded self-assembled polypeptide nanoparticle controls cellular uptake j o u r n a l p r e -p r o o f journal pre-proof the design, synthesis, and evaluation of molecules that enable or enhance cellular uptake: peptoid molecular transporters unexpected multivalent display of proteins by temperature triggered selfassembly of elastin-like polypeptide block copolymers design and cellular internalization of genetically engineered polypeptide nanoparticles displaying adenovirus knob domain tear-mediated delivery of nanoparticles through transcytosis of the lacrimal gland triple stimulus-responsive polypeptide nanoparticles that enhance intratumoral spatial distribution a rapamycin-binding protein polymer nanoparticle shows potent therapeutic activity in suppressing autoimmune dacryoadenitis in a mouse model of sjögren's syndrome elastin-based protein polymer nanoparticles carrying drug at both corona and core suppress tumor growth in vivo noncanonical self-assembly of highly asymmetric genetically encoded polypeptide amphiphiles into cylindrical micelles a hybrid protein-polymer nanoworm potentiates apoptosis better than a monoclonal antibody an amphipathic alpha-helical peptide from apolipoprotein a1 stabilizes protein polymer vesicles self-assembly of thermally responsive nanoparticles of a genetically encoded peptide polymer by drug conjugation a paclitaxel-loaded recombinant polypeptide nanoparticle outperforms abraxane in multiple murine cancer models niclosamide-conjugated polypeptide nanoparticles inhibit wnt signaling and colon cancer growth encapsulating a hydrophilic chemotherapeutic into rod-like nanoparticles of a genetically encoded asymmetric triblock polypeptide improves its efficacy active targeting of cancer cells by nanobody decorated polypeptide micelle with bioorthogonally conjugated drug recombinant synthesis of hybrid lipid-peptide polymer fusions that self-assemble and encapsulate hydrophobic drugs silk-elastin-like protein biomaterials for the controlled delivery of therapeutics tunable self-assembly of genetically engineered silk--elastin-like protein polymers hydrophobic drug-triggered self-assembly of nanoparticles from silk-elastin-like protein polymers for drug delivery injectable intratumoral depot of thermally responsive polypeptide-radionuclide conjugates delays tumor progression in a mouse model brachytherapy using injectable seeds that are self-assembled from genetically encoded polypeptides <em&gt injectable polypeptide micelles that form radiation crosslinked hydrogels in situ for intratumoral radiotherapy one-month zero-order sustained release and tumor eradication after a single subcutaneous injection of interferon alpha fused with a body-temperature-responsive polypeptide injectable protease-operated depots of glucagon-like peptide-1 provide extended and tunable glucose control one-week glucose control via zero-order release fusion of fibroblast growth factor 21 to a thermally responsive biopolymer forms an injectable depot with sustained anti-diabetic action a thermo-responsive protein treatment for dry eyes sustained release of antibiotics from injectable and thermally responsive polypeptide depots development and characterization of a fusion protein between thermally responsive elastin-like polypeptide and interleukin-1 receptor antagonist: sustained release of a local antiinflammatory therapeutic phasebio-announces-global-license-of-pb1023-forthe-treatment-of-sarcopenia-related-diseases-to-immunoforge.html phasebio announces case study highlighting pb1046 hemodynamic data presented at the 14th pulmonary vascular research institute world congress mechanism of resilin elasticity resilin-like polypeptide hydrogels engineered for versatile biological functions resilin-based materials for biomedical applications tentative identification of a resilin gene in drosophila melanogaster synthesis and properties of crosslinked recombinant pro-resilin comparisons of recombinant resilin-like proteins: repetitive domains are sufficient to confer resilinlike properties structural ensembles reveal intrinsic disorder for the multi-stimuli responsive bio-mimetic protein rec1-resilin purification of recombinant protein by cold-coacervation of fusion constructs incorporating resilininspired polypeptides a genetically engineered protein responsive to multiple stimuli a ph-responsive interface derived from resilin-mimetic protein rec1-resilin temperature-triggered phase separation of a hydrophilic resilinlike polypeptide ph-responsive schizophrenic diblock copolymers hydration changes during thermosensitive association of a block copolymer consisting of lcst and ucst blocks switching the inside and the outside of aggregates of water-soluble block copolymers with double thermoresponsivity micellar self-assembly of recombinant resilin-/elastin-like block copolypeptides hydrophilic elastomeric biomaterials based on resilin-like polypeptides tunable mechanical stability and deformation response of a resilin-based elastomer characterization of resilin-based materials for tissue engineering applications targeting angiogenesis: structural characterization and biological properties of a de novo engineered vegf mimicking peptide expression, cross-linking, and characterization of recombinant chitin binding resilin redox-responsive resilin-like hydrogels for tissue engineering and drug delivery applications resilin-like polypeptide hydrogels engineered for versatile biological function design and production of a chimeric resilin-, elastin-, and collagen-like engineered polypeptide genetically engineered silk-elastinlike protein polymers for controlled drug delivery the enhanced permeability and retention (epr) effect in tumor vasculature: the key role of tumor-selective macromolecular drug targeting design of silk-elastin-like protein nanoparticle systems with mucoadhesive properties in-situ self-assembling protein polymer gel systems for administration, delivery, and release of drugs solute diffusion in genetically engineered silk-elastinlike protein polymer hydrogels controlled release of plasmid dna from a genetically engineered silk-elastinlike hydrogel in vitro and in vivo evaluation of recombinant silk-elastinlike hydrogels for cancer gene therapy adenoviral gene delivery to solid tumors by recombinant silk-elastinlike protein polymers comparison of silk-elastinlike protein polymer hydrogel and poloxamer in matrix-mediated gene delivery silk-elastin-like hydrogel improves the safety of adenovirus-mediated gene-directed enzyme−prodrug therapy direct observation of interactions of silk-elastinlike protein polymer with adenoviruses and elastase temperature-responsive silk-elastinlike protein polymer enhancement of intravesical drug delivery of a therapeutic glycosaminoglycan for treatment of interstitial cystitis/painful bladder syndrome silk-elastinlike protein polymers enhance the efficacy of a therapeutic glycosaminoglycan for prophylactic treatment of radiation-induced proctitis a recombinant polypeptide extends the in vivo half-life of peptides and proteins in a tunable manner multivalent antiviral xten-peptide conjugates with long in vivo half-life and enhanced solubility extension of in vivo half-life of biologically active molecules by xten protein polymers safety, pharmacokinetics, and pharmacodynamics of a single subcutaneous dose of vrs-859 in patients with type 2 diabetes gcg-xten: an improved glucagon capable of preventing hypoglycemia without increasing baseline blood glucose glp2-2g-xten: a pharmaceutical protein with improved serum half-life and efficacy in a rat crohn's disease model xten-annexin a5: xten allows complete expression of long-circulating protein-based imaging probes as recombinant alternative to pegylation vrs-317), a long-acting rhgh, in pediatric growth hormone deficiency safety and efficacy of somavaratan (vrs-317), a long-acting growth hormone, in children with growth hormone deficiency (ghd): 2.5-year results from the vista trial prolonged half-life and improved recovery of recombinant factor ix-xten fusion proteins in hemophilia b mouse model safety and prolonged activity of recombinant factor viii fc fusion protein in hemophilia a patients long-term safety and efficacy of recombinant factor viii fc fusion protein (rfviiifc) in subjects with haemophilia a bivv001, a new class of factor viii replacement for hemophilia a that is independent of von willebrand factor in primates and mice xten as biological alternative to pegylation allows complete expression of a protease-activatable killin-based cytostatic off-tumor toxicity with potent efficacy in vitro and in vivo and large safety margins in nhp pasylation: a biological alternative to pegylation for extending the plasma halfactive proteins influence of size and charge of unstructured polypeptides on pharmacokinetics and biodistribution of targeted fusion proteins fusion proteins for half-life extension of biologics as a strategy to make biobetters enhanced in vivo efficacy of a type i interferon superagonist with extended plasma half-life in a mouse model of multiple sclerosis pasylation technology improves recombinant interferon-β1b solubility, stability, and biological activity pasylation of murine leptin leads to extended plasma half-life and enhanced in vivo efficacy treatment of diet-induced lipodystrophic c57bl/6j mice with long-acting pasylated leptin normalises insulin sensitivity and hepatic steatosis by promoting lipid utilisation molecular design, expression and evaluation of pasylated human recombinant erythropoietin with enhanced functional properties pasylated coversin, a c5-specific complement inhibitor with extended pharmacokinetics, shows enhanced anti-hemolytic activity in vitro pasylation®: a versatile technology to extend drug delivery improved doxorubicin encapsulation and pharmacokinetics of ferritin-fusion protein nanocarriers bearing proline, serine, and alanine elements selective delivery of doxorubicin by novel stimuli-sensitive nano-ferritins overcomes tumor refractoriness influence of defined hydrophilic blocks within oligoaminoamide copolymers: compaction versus shielding of pdna nanoparticles, polym comparison of peptides from wheat gliadin and glutenin bioadhesive potential of gliadin nanoparticulate systems evaluation of gliadins nanoparticles as drug delivery systems: a study of three different drugs gliadin nanoparticles as carriers for the oral administration of lipophilic drugs anticancer drug-loaded gliadin nanoparticles induce apoptosis in breast cancer cells anti-helicobacter pylori effect of mucoadhesive nanoparticles bearing amoxicilin in experimental gerbils model fractionation of soybean globulins using ca2+ and mg 2+: a comparative analysis effect of concentration, ionic strength and freeze-drying on the heat-induced aggregation of soy proteins development of a bio-based composite material from soybean oil and keratin fibers nanoparticles synthesized from soy protein: preparation, characterization, and application for nutraceutical encapsulation soy protein/soy polysaccharide complex nanogels: folic acid loading, protection, and controlled delivery in vitro study of the release properties of soy-zein protein microspheres with a dynamic artificial digestive system elaboration and characterization of soy/zein protein microspheres for controlled nutraceutical delivery lactobacillus casei loaded soy protein-alginate microparticles prepared by spray-drying soy protein films for wound-healing applications: antibiotic release, bacterial inhibition and cellular response gelation modification of soy protein isolate by a naturally occurring cross-linking agent and its potential biomedical application kinetics of the breakdown of crosslinked soy protein films for drug delivery soy matrix drug delivery systems obtained by melt-processing techniques drug sorption onto and release from soy protein fibers microspheres of corn protein, zein, for an ivermectin drug delivery system zein in controlled drug delivery and tissue engineering three-dimensional structure of maize α-zein proteins studied by small-angle x-ray scattering fabrication, gastromucoadhesivity, swelling, and degradation of zein-chitosan composite ultrafine fibers pectin/zein beads for potential colon-specific drug delivery: synthesis and in vitro evaluation study of a pingyangmycin delivery system: zein/zein-saib in situ gels doxorubicin-loaded zein in situ gel for interstitial chemotherapy novel preparation of zein microspheres conjugated with ps-k available for cancer immunotherapy preparation of zein microspheres conjugated with antitumor drugs available for selective cancer chemotherapy and development of a simple colorimetric determination of drugs in microspheres antibacterial activity of ciprofloxacin-loaded zein microsphere films preparation and in vitro release of zein microparticles loaded with prednisolone for oral delivery simple coacervates of zein to encapsulate gitoxin preparation of new 5-fluorouracil-loaded zein nanoparticles for liver targeting doxorubicin-loaded biodegradable self-assembly zein nanoparticle and its anti-cancer effect: preparation, in vitro evaluation, and cellular uptake encapsulation of lovastatin in zein nanoparticles exhibits enhanced apoptotic activity in hepg2 cells fabrication of plant protein microspheres for encapsulation, stabilization and in vitro release of multiple anti-tuberculosis drugs preparation and characterization of zein and zein-chitosan microspheres with great prospective of application in controlled drug release invited review: caseins and the casein micelle: their biological functions, structures, and behavior in foods1 potential of casein as a carrier for biologically active agents milk nutritional composition and its role in human health formation and potential uses of milk proteins as nano delivery vehicles for nutraceuticals: a review unique milk protein based nanotubes: food and nanotechnology meet preparation of nanoparticles from denatured whey protein by ph-cycling treatment heat stability of micellar casein concentrates as affected by temperature and ph casein micelle as a natural nanocapsular vehicle for nutraceuticals, food hydrocoll fluorescence study of the curcumin−casein micelle complexation and its application as a drug nanocarrier to cancer cells beta-casein nanovehicles for oral delivery of chemotherapeutic drugs livney, β-casein-based nanovehicles for oral delivery of chemotherapeutic drugs: drug-protein interactions and mitoxantrone loading capacity doxorubicin-loaded casein nanoparticles for drug delivery: preparation, characterization and in vitro evaluation casein nanoparticles as carriers for the oral delivery of folic acid, food hydrocoll novel ionically crosslinked casein nanoparticles for flutamide delivery: formulation, characterization, and in vivo pharmacokinetics nio, &alpha; s1 -casein film prepared using the manufacture and characterization of casein films as novel tablet coatings genipin-crosslinked casein hydrogels for controlled drug delivery novel casein hydrogels: formation, structure and controlled drug release influence of sodium caseinate on the dissolution rate of hydrochlorothiazide and chlorothiazide dissolution mechanism of ibuprofen-casein compacts the effects of casein on diclofenac release from hydroxypropylmethylcellulose (hpmc) compacts evolution of the transferrin family: conservation of residues associated with iron and anion binding transferrin receptor 1 in cancer: a new sight for cancer therapy exploiting transferrin receptor for delivering drugs across the blood-brain barrier relationship between therapeutic efficacy of doxorubicin-transferrin conjugate and expression of p-glycoprotein in chronic resistant to doxorubicin efficacy of doxorubicin-transferrin conjugate in apoptosis induction in human leukemia cells through reactive oxygen species generation inducing cell death in vitro in cancer cells by targeted delivery of cytochrome c via a transferrin conjugate self-assembled ir780-loaded transferrin nanoparticles as an imaging, targeting and pdt/ptt agent for cancer therapy transferrin fusion technology: a novel approach to prolonging biological half-life of insulinotropic peptides fusion protein technologies for biopharmaceuticals : applications and challenges effects of receptor binding on plasma half-life of bifunctional transferrin fusion proteins exploiting iron-binding proteins for drug delivery reconstituted and native iron-cores of bacterioferritin and ferritin humanized archaeal ferritin as a tool for cell targeted delivery cisplatin encapsulation within a ferritin nanocage: a high-resolution crystallographic study high hydrostatic pressure encapsulation of doxorubicin in ferritin nanocages with enhanced efficiency ferritin nanocarrier traverses the blood brain barrier and kills glioma h-ferritinnanocaged doxorubicin nanoparticles specifically target and kill tumors with a single-dose injection h-ferritin-nanocaged olaparib: a promising choice for both brca-mutated and sporadic triple negative breast cancer biomineralization synthesis of the cobalt nanozyme in sp94-ferritin nanocages for prognostic diagnosis of hepatocellular carcinoma ferritin-mediated sirna delivery and gene silencing in human tumor and primary cells a.v. and s.s. contributed equally to this work. a.v. acknowledges the support of the nsf through a graduate research fellowship. 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